Oversees and monitors the system-wide HIM Clinical Documentation Program to improve overall quality and completeness of clinical documentation and accurately reflect patient severity of illness and risk of mortality. Facilitates modifications to clinical documentation to ensure completeness through extensive interaction with physicians or medical staff departments. Oversees day-to-day departmental operations and personnel responsible for facilitating necessary documentation in the medical record. Verifies monthly data entry and verifies staff reporting regarding documentation in the medical record. Develops and implements weekly/monthly/quarterly training to educate physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record. Facilitates education for members of the patient care team regarding specific documentation needs and reporting/reimbursement issues identified through daily and retrospective documentation reviews and aggregate data analysis. Leads the monthly staff education team corrections process. Performs analysis and trending of statistical data for specified patient populations to identify opportunities for improvement. Prepares and presents clinical documentation monitoring/trending reports for review with physicians and hospital leadership. Leads change processes required to capture needed documentation, such as forms redesign. Partners with the coding leadership to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, and/or risk of mortality. Identifies the need for policy development and/or revision, defines policies in collaboration with higher level management input, goals and objectives. Takes the lead in maintaining accurate documentation awareness and initiatives including written and electronic medical record information, DRG assignment and ICD-9-CM code assignment to meet regulatory and billing requirements daily.
Oversees or directs the development and/or revision of department procedures/protocols. Approves procedures/protocols and/or seeks other departmental approvals as appropriate. Develops monitors and revises functional processes. Provides input into the development and revision of organizational structure for function. Approves personnel actions such as hires, fires, disciplines, etc. Ensures the timely completion of performance appraisals. Develops current to intermediate goals and measures for area of responsibility. Measures and assesses performance. As requested, assists in long range goal development. Assists in development of and monitors department budget.
Monitors activities for and ensures compliance with laws, government regulations, Joint Commission requirements and our policies. As directed, implements external and internal audit recommendations. .
Minimum Qualifications
1. Bachelor’s degree in Nursing or Health Information Management or related field, or the equivalent combination of education and/or experience.
2. Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA) or eligible, Certified Coding Specialist (CCS) or Registered Nurse (RN).
3. Five years of hospital-based health information management experience or clinically well-rounded medical or surgical acute care nursing experience. Critical care nursing experience preferred.
4. Two years of progressively more responsible management experience in an acute care facility including frequent involvement with senior management and physicians.
5. Financial analysis billing or reimbursement experience strongly preferred.
Skills Required
1. Analytical ability to create solutions to difficult administrative, technical or human situations, to anticipate and resolve a broad range of issues and concerns on multiple, sometimes unrelated topics, to determine the need for process development and refinement, to independently evaluate situations and outline ramifications of multiple solutions or options, to recommend goals for function/area and understand when intervention in current work processes must occur to ensure successful delivery of service.
2. Communication and/or interpersonal skills for contact with internal and external customers/stakeholders to obtain and interpret a variety of information based on knowledge of departmental practices,our policies and programs and specific technical and regulatory knowledge. Discretion must be exercised in deciding what and how to communicate. Conflict resolution skills must be exercised where policy issues are concerned both within the functional area and interdepartmentally. Diplomacy, tact and listening skills are required. Ability to read, interpret and write technical materials.
3. Leadership skills including demonstrated willingness to pursue leadership roles with increasing levels of accountability comfort with decision-making responsibilities, coaching, teaching and counseling skills, and the ability to inspire and build confidence in others and to forge alliances and garner support.
4. Strong technical knowledge of clinical documentation guidelines, policies and procedures, and the requirements of third party payers most frequently seen with the our client's patient population.
5. Ability to use computer systems; computer skills and knowledge of various software packages including database and spreadsheet programs.
Oversees or directs the development and/or revision of department procedures/protocols. Approves procedures/protocols and/or seeks other departmental approvals as appropriate. Develops monitors and revises functional processes. Provides input into the development and revision of organizational structure for function. Approves personnel actions such as hires, fires, disciplines, etc. Ensures the timely completion of performance appraisals. Develops current to intermediate goals and measures for area of responsibility. Measures and assesses performance. As requested, assists in long range goal development. Assists in development of and monitors department budget.
Monitors activities for and ensures compliance with laws, government regulations, Joint Commission requirements and our policies. As directed, implements external and internal audit recommendations. .
Minimum Qualifications
1. Bachelor’s degree in Nursing or Health Information Management or related field, or the equivalent combination of education and/or experience.
2. Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA) or eligible, Certified Coding Specialist (CCS) or Registered Nurse (RN).
3. Five years of hospital-based health information management experience or clinically well-rounded medical or surgical acute care nursing experience. Critical care nursing experience preferred.
4. Two years of progressively more responsible management experience in an acute care facility including frequent involvement with senior management and physicians.
5. Financial analysis billing or reimbursement experience strongly preferred.
Skills Required
1. Analytical ability to create solutions to difficult administrative, technical or human situations, to anticipate and resolve a broad range of issues and concerns on multiple, sometimes unrelated topics, to determine the need for process development and refinement, to independently evaluate situations and outline ramifications of multiple solutions or options, to recommend goals for function/area and understand when intervention in current work processes must occur to ensure successful delivery of service.
2. Communication and/or interpersonal skills for contact with internal and external customers/stakeholders to obtain and interpret a variety of information based on knowledge of departmental practices,our policies and programs and specific technical and regulatory knowledge. Discretion must be exercised in deciding what and how to communicate. Conflict resolution skills must be exercised where policy issues are concerned both within the functional area and interdepartmentally. Diplomacy, tact and listening skills are required. Ability to read, interpret and write technical materials.
3. Leadership skills including demonstrated willingness to pursue leadership roles with increasing levels of accountability comfort with decision-making responsibilities, coaching, teaching and counseling skills, and the ability to inspire and build confidence in others and to forge alliances and garner support.
4. Strong technical knowledge of clinical documentation guidelines, policies and procedures, and the requirements of third party payers most frequently seen with the our client's patient population.
5. Ability to use computer systems; computer skills and knowledge of various software packages including database and spreadsheet programs.