System Director, Clinical Documentation Integrity

UCSF Health; San Francisco (CA); On-site; USD 250,000 - 350,000; Full time

Job summary

UCSF Health is seeking a System Director of Clinical Documentation Integrity (CDI) to lead best practices ensuring accurate patient complexity representation across the health system. The role partners with Medical Directors and HIM to optimize DRG assignments, outcomes metrics and reimbursement while aligning with quality goals.

This senior position spans academic, pediatric, community, and ambulatory settings, requiring strategic vision, regulatory knowledge, and strong collaboration with

Qualifications

• Bachelor’s degree in nursing or related health care field or equivalent experience.
• Minimum 8 years of related experience.
• Advanced expertise in clinical documentation, coding, and data management.
• Comprehensive knowledge of regulatory requirements and compliance.
• Strong organizational and prioritization skills.

Skills

Nursing degree

Healthcare experience

Hospital management

Documentation & coding

Regulatory compliance

Education

Bachelor's degree in nursing or related health care field

Tools

Clinical documentation systems

Healthcare IT

Medical records processes

Job description

Job Description

Job Summary: The System Director, Clinical Documentation Integrity (CDI) oversees best practices in clinical documentation to accurately represent patient complexity for all outcomes. The CDI team is part of the Department of Quality and Safety, the System Director reports to the Chief Quality Officer (CQO). The System Director is responsible for a cohesive clinical documentation strategy across the health system to ensure an accurate reflection of severity of illness, resources, and care for quality outcomes and to maximize reimbursement. Includes all inpatient clinical entities – Academic adult population; pediatrics - Benioff Children’s Hospitals; community setting - St Mary’s and St Francis Hospitals; and ambulatory for Medicare Advantage risk adjustment. The Director is a strategic dyad partner with four Medical Directors for the respective clinical entities - setting the vision and standards through the program’s foundation of structure-process-outcomes. The System Director develops partnerships with clinical services and multi-disciplinary teams to ensure precise documentation reflects complex care management. This includes partnering with clinical leaders for standard clinical definitions by service line experts templated into the EMR. In collaboration with the Medical Directors, the Director provides guidance and interpretation of outcomes to supports service line initiatives. The System Director collaborates with the health information management (HIM) leadership for Coding to ensure documentation maximizes DRG assignment for reimbursement and accuracy in quality outcomes. The CDI System Director closely follows team performance related to process and outcome metrics, provider engagement and supports a very significant ROI. The Director follows quality outcomes - case mix index (CMI), patient safety indicators (PSI), hospital acquired conditions (HAC), sepsis and mortality outcomes. The System Director is a strategic leader throughout the organization as the subject matter expert for the True North quality goals. The CDI System Director collaborates with other DOQS leaders and is a multi-disciplinary strategic partner for process improvement opportunities across the health system.

Department Overview

Clinical Documentation Integrity (CDI) is a team within the Department of Quality & Safety that reviews provider documentation and facilitates accurate representation of patients treated across UCSF Health. Through collaborative relationships with clinical teams, CDI supports best practices in documentation improvement strategies with an emphasis on severity of illness, medical complexity and quality in the medical record. CDI closely follows case mix index, risk adjusted outcomes and mortality ratings.

Qualifications

Minimum Requirements:

• Bachelor’s degree in nursing or related health care field, or equivalent combination of education and experience.
• Minimum 8 years of related experience
• Demonstrated hospital management skills, with advanced expertise in clinical documentation and coding, database management, medical records processes and external regulations
• Proven understanding of conditions and diagnoses as they relate to reporting and reimbursement
• Comprehensive knowledge of relevant regulatory requirements, as well as related legislative, accreditation, licensing and compliance environments
• Strong ability to organize, manage multiple priorities, meet deadlines and assign work efficiently

Preferred Qualifications

• Advanced degree in nursing or related health care field (e.g., MPH, MBA, etc,) or equivalent combination of education and experience
• RN: CA RN license
• CCDS certification
• Proven leadership, fiscal and operational management skills, with the ability to collaborate effectively with physicians, management and staff at all levels, and with external agencies
• Advanced knowledge of relevant hardware and software, as well as the specialty applications and healthcare information management systems used in clinical documentation, coding, data management, and reporting