Job Summary
This position provides leadership, direction and oversight for the centralized clinical documentation program across the system. This position provides system oversight, coordination and improvement of the clinical documentation program to the organization and partners with Sr. Leadership and facility-based quality management services in pursuit of best practices to achieve quality outcomes, reduce costs and interpret standards required to ensure a high degree of patient, physician and employee satisfaction. This position is accountable for improving clinical documentation data collection and analysis for system, facility and physician profiling and provides ongoing communication on documentation opportunities, coding and reimbursement issues and overall performance improvement methodologies.
Essential Functions
Plans, directs and monitors the clinical documentation program across the organization. Provides oversight and support for the clinical documentation functions for all Banner facilities and partners with hospital-based quality management services in pursuit of best practice to achieve quality outcomes, reduce costs and interpret the standards required to ensure a high degree of patient, physician and employee satisfaction. Provides advice, counsel, feedback and coordination that promote a collegial relationship between staff, physicians and the leadership team.
Provides leadership and direction for multidisciplinary process improvement activities, including steering committee oversight to attain optimal clinical, operational and financial outcomes. Develops system policy, procedures, and performance tools for program. Provides consultative expertise on coding process, DRGs and reimbursement methodologies to a multitude of organizational teams.
Provides leadership to multifunctional teams in the design and distribution of educational programs associated with clinical documentation for staff and physicians. Formulates action plans based on meeting system initiatives and implements strategies to work with internal and external customers to ensure quality of the clinical documentation system.
Oversees the education, coaching, and mentoring of staff to promote revenue enhancement, improved quality and system integrity throughout the organization. Provides oversight in the compilation of resource information that will extend the knowledge and enhance the interpretive skills of clinicians. Recognizes successes and identify ongoing opportunities by collaborating with clinical and coding leadership to improve program efficiencies.
Directs personnel actions including recruiting, new hire actions, interviewing and selection of new staff, salary determinations, training and annual evaluations. This position also participates in the development of clinical documentation and quality management goals and objectives in accordance with company standards.
Develops and oversees the department budget in conjunction with corporate goals and objectives. This position is accountable for meeting annual budgetary goals. Manages the financial and capital resources for the clinical documentation program by monitoring operating revenue and expenses, establishing and maintaining cost control programs and developing and implementing new or revised programs and/or services.
Oversees the preparation and analysis of performance reports for activities associated with the clinical documentation program on an ongoing basis for system, facility and department comparison. Presents the results and related recommendations to leadership teams.
Maintains current knowledge on laws, regulatory changes and actual practices, which affect clinical documentation, DRG assignment and reimbursement methodologies.
Minimum Qualifications
Requires a level of education as normally obtained through the completion of a bachelors degree in nursing, healthcare information management or related field or equivalent experience.
Requires Registered Nurse (R.N.) license in state worked.
Requires a strong working knowledge of healthcare operations, clinical documentation and reimbursement methodologies as typically obtained through a minimum of 5 years experience in coding and reimbursement methodologies in a hospital setting and at least 2 years of leadership experience.
Must possess the skill set to produce reliable, accurate and credible data that is action-oriented. Must possess strong executive presence and demonstrated flexibility in responding to the needs of multiple constituencies with a service-oriented philosophy. Must also possess demonstrated skill in problem analysis, project management, contract negotiation, conflict resolution and oral/written presentation.
Preferred Qualifications
Masters degree in relevant field preferred.Certified Coding Specialist credential, Registered Health Information Administrator or Registered Health Information Technologist preferred.
Additional related education and/or experience preferred.
