Regional Director – Clinical Documentation Integrity
PAM Health
full-time
Posted on:
Location Type: Office
Location: Enola • Pennsylvania • 🇺🇸 United States
Visit company websiteJob Level
Lead
About the role
- Develops and manages the Clinical Documentation functions/activities at each of the assigned hospitals.
- Acts as a subject matter expert for CDI within the organization and provides assistance with internal hospital initiatives as needed
- Performance of initial reviews, concurrent reviews and retrospective reviews (as appropriate) to ensure the CMG accurately reflects the principal diagnosis and comorbid conditions after study
- Review of the working CMG and identification of conditions POA (present on admission), HAI, HAC, and potential CMG migrations.
- Ensure capture of documentation to support the SOI/ROM and resource consumption associated with the care on a concurrent basis and provides ongoing guidance for assigned hospitals.
- Addresses CDI review opportunities to ensure the documentation is complete and accurate and provide education.
- Analyze clinical information to identify areas within the medical record that are conflicting, imprecise, incomplete, ambiguous, inconsistent, or illegible and queries on a concurrent basis to obtain clarification in the medical record in collaboration with hospital support.
- Utilizes a compliant query process per guidelines and policy when conducting all queries; both written and verbal.
- Monitor, track, trend and report of query rates as related to type, response rates, associates provider, and outcomes.
- Collaborates with hospital staff and providers to promote complete and accurate clinical documentation and to correct negative data trends; acts as a consultant to key stakeholders when additional information is needed.
- Provides CDI education to providers, clinical staff, or departments one on one, during staff meetings or departmental meetings as needed, either remotely or on location.
Requirements
- Graduation from a clinical program, RN, LPN, RT, etc and/or Bachelors of Science in Health Information Management or related degree
- Registered Health Information Administrator and/or Certified Coding Specialist certification
- 5 years+ acute care experience with recent management or supervisory experience
- CCDS or CDIP preferred. Must be willing to obtain CCDS or CDIP within first 2.5 years of employment
Benefits
- Competitive pay
- Generous paid benefit time
- Excellent insurance options
- Professional growth opportunities through our Education Advancement Program
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
clinical documentation improvementinitial reviewsconcurrent reviewsretrospective reviewsquery processdata analysisdocumentation capturemedical record reviewperformance monitoringeducation provision
Soft skills
collaborationcommunicationconsultationleadershipproblem-solvingorganizational skillsinterpersonal skillsguidancetrainingtrend analysis
Certifications
Registered Health Information AdministratorCertified Coding SpecialistCCDSCDIP