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The Director, Clinical Documentation Improvement is responsible for progress towards goals and objectives for the Health System’s Clinical Documentation Improvement program, in collaboration and as directed by the Clinical Documentation leadership team. Based on System-wide initiatives and hospital goals will develop annual CDI workplans and report completed activities to CMO, CNO, CFO and Quality leaders. Annually review the Clinical Documentation program to ensure compliance to state and regulatory guidelines. Participates in and actively supports development and enhancement of clinical documentation, integrity practice with emphasis on quality monitoring, management of on-going competencies for Clinical Documentation Specialists, identification of programmatic opportunities for growth and improvement. This individual provides educational support to the systemwide clinical documentation improvement team to improve accuracy and quality in patient’s medical record and to ensure that diagnoses are an accurate reflection of the patient’s clinical status and care. The Director, CDI is responsible for providing new hire orientation, mentoring, and on-going education to the CDI team, as well as to provide specialty-specific education to physicians and targeted service lines. This individual will serve as a subject matter expert in CDI and provider engagement and reports to the AVP, Clinical Care Transformation.
1. Identify Clinical Documentation improvement issues and foster excellent communication with physicians, nurses, coding, and other members of the health care team to be able to work independently to resolve such issues.
2. Assists CDI team with educational needs, problem resolution, time management, and critical thinking skills development.
3. Implements clinical skills activities within established clinical and preceptorship models, monitors data trends, and implements educational strategies to ensure compliance with quality standards.
4. Collaborates with the Professional Development Department to develop and provide new hire CDI onboarding and department specific orientation program and competencies for new CDI Specialists, as well as educational programs to address and enhance the CDI team performance.
5. Maintains all department training materials, tools and/or records.
6. Develops and maintains department’s web-based collaborative platforms with education topics, performance outcomes by facility and key areas for CDI. Develops and publishes and maintains quarterly department newsletter.
7. Performs quality documentation audits, including chart review and query compliance of patient records, to ensure CDI Specialists and providers are compliant with applicable rules and regulations.
8. Provides mentoring and ongoing feedback to the CDI Team.
9. Engages physicians/providers on CDI topics and attends monthly service line meetings.
10. Develops and presents key CDI topics at all service line meetings.
11. Monitors CDI performance and tracks CDI team knowledge through bi-annual assessment tests.
12. Develops and maintains CDI assessment tests and develops education around topics missed.
13. Provides education to the CDI team related to the annual regulatory updates and changes.
14. Collaborates with Leadership and Medical Directors in the development and delivery of specialty specific education to physicians, departments, and specialties.
15. Evaluates second level review audits for areas of opportunity and develop education sessions to enhance the CDI team performance and/or physician documentation, both as a group and individually to ensure CDI success (IRR).
16. Represents the CDI team at various meetings…