This position has accountability for the daily operations, continual development and supervision of the Clinical Documentation Improvement Program. This position is responsible for the supervision of all Clinical Documentation Specialists , including hiring, performance evaluation and accountability, scheduling, and disciplinary actions. Similarly, he/she is responsible for assisting the Director of Clinical Documentation Improvement with the development of an appropriate budgets and the daily management of those budgets. He/She provides expertise to appropriate hospital personnel regarding clinical management of specific patient populations and oversees the review processes of complex patients in acute and chronic states. He/She will collaborate with interdisciplinary teams including, but not limited to, physicians, nurse practitioners, and the department managers of revenue, coding, case management, and Health Information Management. The manager will be responsible for coordinating physician/provider education regarding CDI across the system.
Clinical Documentation provides a formalized approach to promote accurate and complete medical record documentation reflecting a patient’s true severity of illness and risk of mortality. The CDS reviews inpatient medical records and identifies opportunities in provider documentation that will clarify patient severity of illness, risk of mortality, quality indicator measures and intensity of care rendered. The CDS collaborates with providers and HIM coding staff to ensure accurate clinical documentation by concurrently assigning DRG’s and capturing documentation specificity to support diagnosis and clinical indicators in the medical record.
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