RN Clinical Documentation Manager

Summary 

The Clinical Documentation Manager is responsible for using clinical/nursing knowledge to improve the overall quality and completeness of the hospital's clinical documentation, namely patient records, on a concurrent basis using a multidisciplinary team process. The Clinical Documentation Manager works collaboratively with physicians to ensure clinical information in medical records is present and accurate and works with the coding staff to support that appropriate clinical severity is captured for the level of service rendered to all patients. 

This position requires critical thinking, problem solving, ability of managing multiple priorities, able to work with little or minimum direct supervision, excellent writing skills, clear and accurate verbal communication skills, and ability to work in appropriate computer software. 

Essential Duties and Responsibilities

These duties and responsibilities described below represent the general tasks performed daily; other tasks may be assigned. 

• Develop and manage the Clinical Documentation Program to meet department and hospital targets and goals 
• Manage and oversee the daily operational clinical documentation activities, data collection, analysis, and reports 
• Provide concurrent documentation review, DRG and coding reviews that ensure high quality documentation 
• Participate on the denial team, ICD-10 team, and conduct studies as necessary to demonstrate improvement in clinical documentation processes 
• Provides ongoing education to physicians and other clinical care providers, related to documentation, changes in coding, compliance issues, and reimbursement changes 
• Monitor and evaluate staffing and appropriate concurrent clinical documentation reviews by the Clinical Documentation Team 
• Coach and assist in developing Clinical Documentation Specialists, and ensures continuing education is maintained 
• Annually review the Clinical Documentation Program to ensure compliance with state and regulatory guidelines 
• Identify Clinical Documentation improvement issues, and through excellent communication with physicians, nurses, coding staff, and other members of the healthcare team, work independently to resolve issues.
• Report to the Director of Health Information Management on Clinical Documentation monthly activities, reporting, productivity, etc. 
• Identify staff development opportunities, assist in the hiring and orienting of new employees, and perform management and evaluation tasks for the Clinical Documentation Specialists 

Summary of Other Job Duties and Expectations

• Adhere to the Service Excellence Standards and Expectations at Chesapeake Regional Medical Center
• Exhibit excellent customer relations to patients, visitors, physicians, and co-workers
• Exhibit courteous communication skills and an ability to work with others, exercising good judgment in performance of job duties
• Demonstrate courtesy, compassion, and respect to others in adherence of the hospital's philosophy and policy for promoting positive work and customer environments
• Work as a team to continuously improve work quality
• Demonstrate a commitment to flexible work schedules when it is necessary to ensure patient care
• Present self in a positive manner as reflected by personal attire and etiquette
• Attend required hospital-wide orientations, meetings, and in-services
• Demonstrate a commitment to flexible work scheduling when necessary to ensure patient care

Supervisory Responsibilities

Reports to: Director, Health Information Management Supervises: Clinical Documentation Specialists Responsibilities: Budget 

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and Experience

Required Education: Associate degree in related medical field

Preferred Education: Bachelor's degree in related medical field

Experience: 5+ years management or supervisory experience in an acute care setting, advanced experience/expertise in processes regarding complex diseases, and a broad clinical experience in an inpatient setting. Five years' experience in clinical documentation

Certificates, Licenses, Registrations 

Must be certified as a Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP}