In this role, the successful candidate in this position will support the Director and Assistant Directors of the Clinical Documentation Improvement (CDI) department. The CDI Manager will perform day-to-day operational needs including, but not limited to: payroll, requests for time off, submitting office supply orders, scheduling of meetings, development of meeting/presentation materials, assisting with CDI team development and education, as well as identification of areas for process improvement. Based on metric analysis findings, action plans will be developed and disseminated to CDI Director/Assistant Director and HIM Directors who will correct knowledge gaps though on-site education and training for CDI and Coding. This position will also work closely with CDI analyst to optimize use of Epic, identifying gaps and areas for ideal performance. Additionally, this position will be current on CDI best practice standards and support the mission, vision, and values of the NYU Langone Health System CDI program.
In addition to the responsibilities described above, the role may include other responsibilities and duties assigned based upon NYU Langone Health System needs or requirements.
Job Responsibilities:
• Identifies educational opportunities by individual site and individual Clinical Documentation Specialists
• Develop CDI clinical criteria policies for consistency in CDI query and coding practices across the Health System
• Makes site visits and instructs individual coder or CDS as needed to close knowledge gap as needed
• Participates in the daily operations and activities of the CDI program to continually improve documentation
• Trains new staff upon hiring on Epic, DRG strategies, relevant software and best practices
• Maintains an updated orientation checklist, timeline, and ensures all orientation content is pertinent, updated, and completed by new hires in a timely manner
• Stays current on all CDI-related literature and current pathophysiology
• Supports Assistant Director and Director to track metrics, assess ICD-10 capture quality, and 3M profile reports to create charts/graphs for presentation to executive staff and physician leadership
• Supports Assistant Director and Director and strategies analysts to ensure optimization of Epic, VBM and other initiatives
• Communicates orally and in writing in concise understandable terms with all people involved in the development and implementation of applications
• Schedules and prepares content for regular team meetings with CDS department members to address educational, administrative, and other departmental needs
• Meets performance standards by setting goals and objectives, prioritizing work, and using available resources efficiently and effectively
• Supports the program/project manager with the maintenance of project plans and schedules
• Coordinate and work effectively with Clinical Documentation Specialists
• Remains current on upgrades, new products and emerging technologies with 3M and Epic
• Maintain databases, spreadsheets, files, memos and graphic applications utilizing various software programs
• Performs payroll duties including solicitation of vacation requests, entering approved time off, and approval of finalized timecards prior to final sign-off dates (biweekly)
• Will act as CDS as needed for each site if interruptions in staffing due to vacation, resignations, FMLs, etc.
• Monitors retrospective query report for timely assignment and closure of pending accounts
• Responsible for reviewing overall quality and completeness of coding by reconciling differences in the MS-DRG/APR-DRG assignment through comparison and analysis of the coding summary and CDI patient summary against medical record documentation
• Utilizes current CMS coding guidelines, conventions and AHA coding clinics to accurately determine the principal and secondary diagnoses and procedures which effect the MS-DRG assignment
• Communicates with coders, compliance specialists and/or clinical documentation specialists regarding documentation clarification and accurate coding
• Reviews clinical documentation and facilitates modifications, as needed, to ensure that documentation accurately reflects the reason for admission, intensity of service rendered, risk of mortality, severity of illness, and conditions present on admission for all patients, in compliance with government and other regulations
• Provide daily clinical evaluation of the medical record documentation by the Medical Staff and healthcare team in accordance with the hospital’s designated clinical documentation policies and procedures
• Communicate with physicians to ensure accurate and complete documentation is in the medical record. Communication is face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness
• Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team
• Monitors ACDIS site, AHIMA site, publications, CMS updates, and other sources for new regulatory guidelines and requirements
• Reviews and updates educational content regularly and as needed, including presentation content, tip sheets, posters, job aids, digital content, and other modalities
• Communicate with physicians, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients
• Utilizes the hospital’s designated clinical documentation system to identify opportunities for physician and hospital outcomes
• Participates in development of educational materials for shared use by CDI teams across the Health systems to maintain consistent content delivery
• Provides or coordinates education to all internal customers related to compliance, coding, and clinical documentation issues and acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG
• Gather and analyze information pertinent to documentation findings and outcomes
• Contribute to a positive working environment and performs other duties as assigned or directed to enhance the overall efforts of the organization
• Develop physician education strategies to promote complete and accurate clinical documentation and correct negative trends
• Research literature to identify new methods development and overall documentation enhancement
• Assist in the development and reporting of performance measures to the medical staff and other departments and prepare physician specific data information
• Active participation on departmental and hospital committees and assigned Task Force groups
• Maintain interaction with appropriate resources that support growth and education of the CDI Team
• Assists CDI teams to accommodate census fluctuation across sites to ensure ability for CDI to maintain review expectations
• Maintain credentials/licensure/certification
• Participates in select committees and provides education programs as necessary.
• Serves as resource to physicians and other members of the healthcare team in matters relating to published DRG, SOI/ROM, ICD-10 and PCS information
• Maintains a level of practice demonstrating knowledge and understanding of AHIMA Practice Brief and knowledge of compliance and regulatory agency expectations
• Maintains awareness of post discharge charts being held for completion of documentation deficiencies by CDI department and is educated about the effect such charts have on Accounts Receivable (DNFB)
• Assists CDI teams to accommodate census fluctuation across sites to ensure ability for CDI to maintain review expectations
• Other duties as assigned
Minimum Qualifications:
To qualify you must have a Current nursing (RN) license with a Bachelor’s Degree in Nursing, and/or bachelors degree in relevant field with current certification (RHIA, RHIT, and/or CCS), and/or graduate education leading to Physician Assistant (PA) with PA license, and/or graduate education leading to MD, DO, or equivalent degree required. CCDS or CDIP within one year of hire for all candidates. Experience with ICD-10 coding and DRG assignment. 2 years of relevant HIM/clinical documentation improvement experience..
Required Licenses: Am Hlth Info Mgmt Assoc-AHIMA
Preferred Qualifications:
Masters degree in nursing, masters degree in HIM, or related field. 1 year CDI management experience.
Qualified candidates must be able to effectively communicate with all levels of the organization.
NYU Langone Health provides its staff with far more than just a place to work. Rather, we are an institution you can be proud of, an institution where you’ll feel good about devoting your time and your talents.
NYU Langone Health is an equal opportunity and affirmative action employer committed to diversity and inclusion in all aspects of recruiting and employment. All qualified individuals are encouraged to apply and will receive consideration without regard to race, color, gender, gender identity or expression, sex, sexual orientation, transgender status, gender dysphoria, national origin, age, religion, disability, military and veteran status, marital or parental status, citizenship status, genetic information or any other factor which cannot lawfully be used as a basis for an employment decision. We require applications to be completed online.
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NYU Langone Health provides a salary range to comply with the New York state Law on Salary Transparency in Job Advertisements. The salary range for the role is $97,589.95 – $175,000 Annually. Actual salaries depend on a variety of factors, including experience, specialty, education, and hospital need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.
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