Clinical Documentation Improvement Mgr.
: Job Details :

Job SummaryThe Clinical Documentation Improvement Manager (CDIM) oversees high-risk, complex secondary case reviews to ensure accurate provider documentation of clinical conditions and procedures. This role is essential for reflecting the severity of illness, expected mortality risk, patient outcomes, and care complexity. The CDIM collaborates with various healthcare team members, including CDI specialists, coders, and quality analysts, to enhance clinical documentation, improve metrics like GMLOS and LOS, and positively impact the hospital's case mix index. Additionally, the CDIM supervises the CDI team, provides feedback for educational development, and educates clinical providers on documentation practices, all while ensuring compliance with departmental and organizational standards.

Minimum Job Requirements:

Work Experience:Five years of direct patient care in a hospital setting are required. Three years of experience working with inpatient clinical documentation, mortality, PSI, HAC, or other quality-focused reviews are required.Three years of management experience are required. License/Registration/Certification:This position requires either Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP) certification required. The candidate must obtain certification within two years of starting the role. Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), or Certified Professional Coder (CPC) is preferred. If candidate is a Registered Nurse, a current Texas Registered Nurse license is required. Education and Training:Bachelor's Degree in Nursing, Master's degree in Nursing preferred, ORMaster's degree in a health related field. OR Graduate from an accredited medical school with an MD or equivalent is required. Skills:

Extensive clinical knowledge, critical-thinking skills, and understanding of disease processes, pathophysiology, and disease management/treatment.

Knowledge of Vizient, Premier, US News and World Report, CMS star rating or similar risk-adjustment methodologies highly preferred.

Proficiency with CDI software (EZDI), CERNER and encoder. Experience with 3M 360 Encompass preferred.

General knowledge of office procedures and operations.

Knowledge of US News and World Report risk-adjustment systems to identify clinical documentation improvement opportunities preferred.

Skill in data entry with minimal errors.

Ability to accurately prepare and maintain records, files, reports and correspondence.

Ability to communicate effectively in both oral and written form.

Ability to handle difficult and stressful situations with professional composure.

Ability to maintain effective interpersonal relationships.

Ability to understand and follow instructions.

Proficiency with ICD-10-CM/PCS, APR DRG, and MS DRG required.