BJC Healthcare Clinical Improvement Documentation Manager - Full Time in Saint Louis, Missouri
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Barnes-Jewish Hospital at Washington University Medical Center is the largest hospital in Missouri and is ranked as one of the nation's top hospitals by U.S. News ; World Report.; Barnes-Jewish Hospital's staff is composed of full-time academic faculty and community physicians of Washington University School of Medicine, supported by a house staff of residents, interns, fellows and other medical professionals.; Recognizing its excellence in nursing care, Barnes-Jewish Hospital was the first adult hospital in Missouri to be certified as a ;Magnet Hospital; by the American Nurses Credentialing Center.
Manages the clinical documentation improvement program, identifying areas of focus for improvement opportunity through report analysis interpretation of process and operational reports, financial and compliance reports, and quality ratings reports. Assists with various associated operational matters including appropriate scheduling and coverage of reviews, query development and auditing, educating physicians, monitoring the program, and refining the process as needed to clarify documentation in records. Coordinates follow-up on unanswered queries during the patient stay, as needed, to obtain prompt response to open queries.Serves as a resource to physicians and administration regarding issues related to the appropriateness of inpatient DRG assignment. Works collaboratively with the CDI team to facilitate documentation within the medical record that supports patients severity of illness and risk of mortality utilizing strong communication skills with physician, physician extender, case manager, utilization reviewer, nurse or other healthcare professionals, utilizing appropriate querying tools to capture needed documentation.
Manages individual(s) including but not limited to: hires, trains, assigns work, manages & evaluates performance, conducts professional development plans. Ensures that the productivity and actions of that group meet/support the overall operational goals of the department as established by department leadership.
Develops and adheres to departmental staffing, revenue and/or expense budgets. Responds to changes in the business which may affect the ability to achieve the budget goals.
Demonstrates a thorough understanding of the MS-DRG system, CCs/MCCs, impact on quality, and CMI as well as ICD-10 coding systems and the guidelines related to Clinical Documentation Improvement. Serves as a resource for the Clinical Documentation Specialist (CDS) team, for any of the above.
Oversees second level chart review processes to ensure appropriate documentation to support PSI/HAC diagnoses, most appropriate principle diagnosis, DRG and POA assignment, and completeness of all supporting documentation.
Works collaboratively with the CMO office, Other Departments, Other Physician Leaders/Liaisons and other resources to clarify and/or otherwise improve documentation in order to accurately support diagnosis and quality indicators for care rendered to patients.
Develops policies and procedures to support best practices for CDI program and clinical documentation staff. Ensures all compliance and regulatory standards are met.
- Associate's Degree
- 5-10 years
- 2-5 years
Licenses & Certifications
Note: not all benefits apply to all openings
- Comprehensive medical, dental, life insurance, and disability plan options- Pension Plan/403(b) Plan- 401(k) plan with company match- Tuition Assistance- Health Care and Dependent Care Reimbursement Accounts-On-Site Fitness Center (depending on location)-Paid Time Off Program for vacation, holiday and sick time
The above information on this description has been designed to indicate the general nature and level of work performed by employees in this position. It is not designed to contain or be interpreted as an exhaustive list of all responsibilities, duties and qualifications required of employees assigned to this job.
Equal Opportunity Employer