Position Summary / Career Interest:

Oversees the daily activities of the Clinical Documentation Integrity (CDI) program at The University of Kansas Health System. Monitors CDS metrics including productivity, code assignment, and query content and quality. Fosters provider engagement, relationships, and collaboration with the CDI team. Develops and conducts ongoing education for new staff, including new CDS, physicians, residents, nurses, and other allied health professionals. Supports CDI relations and development. Demonstrates a collaborative approach with Health Information Management, Finance, Compliance, Coding, Physician advisors, Medical Directors and other hospital departments, to improve the overall quality and completeness of clinical documentation. Identifies CDS education, training, performance monitoring, and CDI technology implementation. Manages the Pre/Post bill process. Manages reconciliation and query processes. Collaborates with extradepartmental departments to improve organizational metrics. Review analytics to identify areas for improvement and challenges associated with CMI and other data measures. Participates in monthly steering committees. Is guided by the Association of Clinical Documentation Integrity Specialists (ACDIS) "Code of Ethics" and the American Health Information Management Association's (AHIMA) "Ethical Standards for Clinical Documentation Improvement Professionals" and the Official Guidelines for Coding and Reporting. These functions are performed in accordance with all applicable laws and regulations and healthy system philosophy, policies, procedures and standards.


Responsibilities and Essential Job Functions

• Ensures the CDS duties are performed accurately and efficiently following all applicable rules and regulations.
• Manages CDI workflow to consistently meet the CDS performance standards including, but not limited to, productivity (initial reviews and follow up reviews), query rate, and documentation clarification rate.
• Develops and maintains reporting tools specific to productivity and outcomes.
• Evaluates the daily functions of the CDI staff to identify and resolve process issues and maintain productivity.
• Analyzes, assesses, and interprets clinical data to identify gaps, inconsistencies, and/or opportunities for improvement in the clinical documentation.
• Develops CDS audit plan and schedule. Performs audits on all CDS reviews and provides performance feedback and summaries to CDI staff and leadership to achieve outcomes.
• Conducts second level reviews and identifies missed query opportunities on conditions necessitating additional clarification within the medical record. This includes quality indicators and risk adjustment conditions.
• Facilitates modifications to the record to ensure that documentation accurately reflects each patient’s severity of illness and risk of mortality.
• Maintains work queues for bundled DRG’s, mortality records, risk adjustment, and all charts deemed to require a second level review.
• Facilitates improvement in the overall quality, completeness, and accuracy of medical record documentation through extensive interaction with clinicians.
• Collaborates with the CDI Physician Advisors, Physician Champions, Department Chairs, CMO/CMIO, coding staff, clinical quality staff, analytics staff and leadership to assess CDI opportunities and implement solutions to ensure program success.
• Utilizes data, technology, and creates reports, process flows and action plans to improve performance.
• Ensures departmental tracking logs are kept current and presents productivity and impact metrics to leadership.
• Applies benchmarks, monitors performance, implements improvements, and tracks progress.
• Represents the CDI department at internal and external meetings as required.
• Works with EMR support team to ensure proper documentation templates are created and maintained.
• Manages the Human Resources activities for direct reports and department staff regarding recruiting and selection, hiring and termination, training, professional development, mentoring, counseling and performance evaluations.
• Coordinates CDS schedules to ensure appropriate coverage.
• Assumes leadership regarding technology application related to CDI.
• Develops and conducts ongoing education for new staff, including new CDS, physicians, residents, nurses, and other allied health professionals. Collaborates with internal and external key customers including Finance, HIM, Compliance, Physician liaisons, Medical Directors, Payers, Providers, and Care Management department staff to achieve improved outcomes.
• Formulates, recommends, implements, monitors and controls operational budgets within administrative guidelines.
• Appraises forecasts and determines desired set of future conditions and strategies required to achieve the goals and objectives of the organization within incumbent’s area of expertise.
• Must be able to perform the professional, clinical and or technical competencies of the assigned unit or department.
• These statements are intended to describe the essential functions of the job and are not intended to be an exhaustive list of all responsibilities. Skills and duties may vary dependent upon your department or unit. Other duties may be assigned as required.

Required Education and Experience

• Bachelors Degree in Health Information Managment, Nursing or a related field of study from an accredited college or university. OR
• 7 or more years of experience in Clinical Documentation Integrity program if from a non clinical field.
• 5 or more years of experience in acute nursing if from the clinical field.
• 2 or more years supervisory or leadership experience in CDI, revenue cycle or a related field.

Preferred Education and Experience

• Master Degree Nursing in Health Information Management, Business Administration, Nursing or a related field of study from an accredited college or university.
• 8 or more years of experience in multi-specialty physician coding.
• 6 or more years of experience in Epic EHR, encoder and other CDI tools.

Required Licensure and Certification

• Must have a current Registered Nurse license in the State of Kansas or a Compact state license for RN's. OR
• Foreign medical graduate (MD) with CDI certification of CCDS or CDIP may be accepted in lieu of RN license
• Registered Health Information Technician (RHIT)-American Health Information Management Association (AHIMA) and Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP). OR
• Registered Health Information Administrator (RHIA)-American Health Information Management Association (AHIMA) and Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP) OR
• Certified Coding Specialist (CCS) and Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP).

We are an equal employment opportunity employer without regard to a person’s race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, ancestry, age (40 or older), disability, veteran status or genetic information.