RN/RHIA Clinical Documentation Improvement Manager

At Saint Alphonsus Health System, we are looking for people who are living out their calling. We want you to be passionate about coming to work, and challenged to achieve your potential. Living by these virtues, we pride ourselves on exceptional service and the highest quality of care. Provides day-to-day management of the Clinical Document Improvement program for Saint Alphonsus Health System (SAHS). Works with the SAHS Regional HIM Director to ensure the SAHS CDI program is compliant with Trinity Health CDI program standards, policies, procedures, and workflows. Provides training and education to clinical documentation specialists (CDS) to enhance clinical and coding skill sets and optimal utilization of the 3M CDI software. Performs data analysis and identifies focus areas and/or opportunities for documentation improvement. Through interaction with providers and members of the healthcare team, achieves appropriate clinical documentation to support the medical necessity and level of services rendered. Develops and delivers education for providers and members of the healthcare team

SKILLS, KNOWLEDGE, EDUCATION AND EXPERIENCE:

  • Must be certified or licensed as one of the following: 
    • Licensed in the State of Idaho or Oregon as a Registered Nurse (RN) as defined by the State Board of Nursing
    • Certified as a Registered Health Information Administrator (RHIA) by the American   Health Information Management Association (AHIMA)
    • Certified as a Registered Health Information Technologist (RHIT) by the American Health Information Management Association (AHIMA)
    • Certified as a Coding Associate (CCA) by the American Health Information Management Association (AHIMA) or a Professional Coder (CPC) by the American Academy of Professional Coders (AAPC) preferred.
  • Bachelor's degree in healthcare related field required.
  • Minimum of one year of professional experience in a hospital clinical documentation improvement program required.
  • Demonstrated previous progressive management or leadership experience in healthcare required.
  • Ability to maintain a professional attitude and relate well with management, physicians, other care providers, colleagues and patients.
  • Demonstrated excellence with written and oral communication skills in a variety of communication settings and styles.
  • Demonstrated excellent interpersonal skills with ability to build collaborative working relationships with clinical staff, finance and compliance.
  • Demonstrated strong analytical skills in order to understand how the data impacts revenue cycle and quality metrics. Intermediate computer skills required, including working knowledge of and experience using MS Word, Excel, Outlook and PowerPoint.  
  • Must be able to spend majority of work time utilizing a computer, monitor, and keyboard. Ability to address complex problems with multi-level impacts using sound judgment, in depth analysis and expertise to resolve issues. Ability to work in a fast-paced, multi-customer environment, with conflicting needs. 
  • May warrant varied and/or extended hours, with changes in workload and priorities to keep pace with the industry and advanced strategic priorities.
  • Current, unrestricted driver's license and ability to travel to Saint Alphonsus Health System and Trinity Health locations as needed.
  • Personal presence that is characterized by a sense of honesty integrity, and caring as well as the ability to inspire and to motivate others to promote the philosophy, mission, vision, goals, and values of the Ministry.

ESSENTIAL FUNCTIONS:

  • Knows, understands, incorporates, and demonstrates the Organization's Mission, Vision, and Values in behaviors, practices, and decisions.
  • Understands and communicates appropriate clinical documentation to ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record. 
  • Assists in overall quality, timeliness and completeness of the quality health record to ensure appropriate data, provider communication, and quality outcomes. 
  • Serves as a resource for appropriate clinical documentation. Develops CDS team through hiring, maintaining work schedules, balancing workload, and conducting performance evaluations. 
  • Mentors and coaches colleagues to ensure positive outcomes.
  • Communicates with and educates physicians and all other members of the healthcare team regarding clinical documentation, and monitors provider participation. 
  • Identifies learning opportunities for healthcare providers. 
  • Conducts concurrent reviews of selected patient health records to address clarity, completeness, consistency, and precision of clinical documentation reviews performed by team. 
  • Identifies opportunities for educational growth and improvement. Collaborates with coding leaders to assure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care. 
  • Resolves all discrepancies in a courteous manner.
  • Demonstrates expertise in problem-solving skills based on theoretical knowledge, clinical experience and sound judgment and serves as a professional role model by demonstrating desirable practice behaviors.
  • May perform CDI reviews to support program during high volume, short staffing periods. Maintains a working knowledge of applicable Federal, State and local laws and regulations, accrediting agencies,
  • Trinity Health’s Organizational Integrity Program, Standards of Conduct, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.

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To perform this job successfully, an individual must be able to perform the competencies / essential functions satisfactorily with or without reasonable accommodation.

Disclaimer: The above statements are intended to describe the general nature and level of work being assigned to this job. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of individuals in the job.