Job Summary

This position will be responsible for coordinating the activities of the Clinical Documentation Specialists (Coders and Nurses) to include scheduling, filling in where needed, and supporting the work of the Clinical Documentation Specialists (CDS). This position will act in an advisory capacity to the CDS staff, helping to resolve problems and issues with documentation. This position will be a liaison with the medical staff, acting on behalf of the documentation program and the hospital to train physicians and to garner cooperation in improving documentation practices. Attending medical staff meetings to provide education as needed and on routine basis.

Responsibilities

• Works with multiple committees and work groups to improve the understanding of the importance of accurate documentation.

• Works to create an environment to support compliant and accurate documentation and coding.

• Continues to monitor the literature to identify new documentation opportunities and works with the CDIP staff to implement actions to correct documentation.

• Pursues and encourages documentation credentialing to demonstrate advanced skill sets in documentation.

• Reviews coding updates each year to identify changes that impact clinical documentation. Develops an educational plan for staff, medical staff, and other CAMC employees and presents information in an effective format.

• Monitors the work of the Clinical Documentation Specialists to insure appropriate querying policies are being followed. Reports results to the HIM Coding manager on a routine basis.

• Produces monthly reports of the activities and outcomes of the CDIP each month and distributes to the senior leadership and other appropriate personnel.

• Reviews medical records and analyzes shifts in data to identify issues.

• Identifies issues that can be remediated and takes appropriate steps. Reports issues to the appropriate sources.

• Performs ongoing examination of work of the clinical documentation specialists and the data registry staff for accuracy, completeness, and productivity.

• Monitors the use of query forms and develops and/or edits query forms as appropriate to sustain compliance with regulations and to provide sufficient forms to allow the clinical documentation specialists to perform their duties adequately on an ongoing basis.

• Works with the HIM Coding Manager to hire and discipline staff as well as to complete performance reviews.

• Works closely with coding supervisory personnel to evaluate and reimbursement on an ongoing basis; rewrites policies and/or develops new policies to guide staff in appropriate actions.

• Performs scheduling for the CDIP and cardiovascular registry staff.

• Monitors changes with other registries utilizing nurses to collect data. This includes, but is not limited to the STS Registry and the AICD Registry.

• Serves as the resource expert for the cardiovascular registries that supports benchmarking with CAMC experiences form the national databases.

Knowledge, Skills & Abilities

Patient Group Knowledge (Only applies to positions with direct patient contact)

The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment or care as defined by the department’s identified patient ages. Specifically the employee must be able to demonstrate competency in: 1) ability to obtain and interpret information in terms of patient needs; 2) knowledge of growth and development; and 3) understanding of the range of treatment needed by the patients.

Competency Statement

Must demonstrate competency through an initial orientation and ongoing competency validation to independently perform tasks and additional duties as specified in the job description and the unit/department specific competency checklist.

Common Duties and Responsibilities
(Essential duties common to all positions)

1. Maintain and document all applicable required education.
2. Demonstrate positive customer service and co-worker relations.
3. Comply with the company's attendance policy.
4. Participate in the continuous, quality improvement activities of the department and institution.
5. Perform work in a cost effective manner.
6. Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations.
7. Perform work in alignment with the overall mission and strategic plan of the organization.
8. Follow organizational and departmental policies and procedures, as applicable.
9. Perform related duties as assigned.

Education 

• Bachelor's Degree (Required) Experience: 7-10 years combination of nursing unit experience and/or clinical documentation improvement. Comment: BSN must be obtained within 3 years of hire. Must have the ability to travel between hospital or CAMC facilities.

Credentials 

• Cert Doc Improvement Prac (Required)
• Registered Nurse (Required)

Work Schedule: Days

Status:  Full Time Regular 1.0

Location: Document Center Building

Location of Job: US:WV:Charleston

Talent Acquisition Specialist: Lauren R. Lane lauren.lane@vandaliahealth.org