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Mgr Regional Clinical Documentation

Wellstar Shared Services • Marietta, GA • Leadership • 109213 • Days, Evenings • Full-Time


The Clinical Documentation Integrity Manager demonstrates a high level of clinical proficiency and critical thinking skills necessary for assisting the Executive CDI Director in creating a support structure within the department for achieving clinical and operational excellence in relation to Clinical Documentation Integrity efforts. Is involved in the direction and education of all phases of the Clinical Documentation process and will be held accountable to work in a collegial manner with physicians, team, and consultants. Collaborates with clinical and non-clinical leadership at Wellstar facilities to achieve system goals in relation to Clinical Documentation Integrity efforts, as well as interdisciplinary teams including, but not limited to, physicians, nurse practitioners, PA's, and the department managers for Revenue, Coding, Care Coordination and Health Information Management. Works collaboratively with other members of the health care team to provide data and solution development processes. Demonstrates ability to design and manage process and workflow improvements, system technology implementations and project management. Demonstrates skill and leadership in managing the operations of the Clinical Documentation Department team and manages the staffing and training needs to meet the expected requirements of the Program. Drives and supports the Departmental goals and philosophy of positive team building, mentoring, coaching and constructive feed-back as well as achieving clinical and operational excellence in relation to Clinical Documentation Integrity efforts. Provides ongoing Clinical Documentation Integrity program education for new team members, including but not limited to, Clinical Documentation Specialists, physicians, nurses and allied health professionals. Plays key role in determining metric measurements that are meaningful to the organization and will assist in analyzing, tracking, trending, and reporting CDI and/or organizational data and metrics at both system and individual facility-level. Actively participates on committees and presents the results of studies, trends, and activities as necessary to demonstrate solution performance and improvement in clinical documentation. Assumes responsibility for professional development through participation in workshops, conferences and/or in-services and maintains appropriate records of participation. Develops team members to encourage and build skills that will support long term department functions.


Remote work available depending on location.”


Core Responsibilities and Essential Functions

  • Develops and manages the Clinical Documentation Improvement Department and activities to meet department and corporate target and goals. Based upon strategic initiatives and departmental goals, develop and adhere to Clinical Documentation Department work plan and report completed activities to CDS Director on a recurring basis and in a timely manner. Manages the daily operational Clinical Documentation Dept. activities, data collection, analysis and reports. Participates on committees and conducts studies as necessary to demonstrate improvement in clinical documentation processes. Monitor and evaluate staffing and appropriate concurrent Clinical Documentation reviews by CDI team. Conducts initial onsite new hire onboarding in partnership with CDI Lead Specialist. Provides an onsite presence, including attending rounds, provider query follow-up, and other facility based assigned duties, and serves as point of contact for questions and clarifications. Attends and participates in routine facility-based committee and other meetings, as assigned by Executive Director. In collaboration with physician partners, presents routine facility-based provider and committee-based education based on trends and other topics.
    * Proficient in negotiating complex systems to effect positive change.
    * Must possess skills required to run a fiscally responsible program while ensuring constant improvement.
    * Extensive knowledge of treatment methodology, patient care assessment, data collection techniques and coding classification systems is necessary. Serve as an expert resource on CDI and DRG issues.
    * Adheres to departmental Policies and Procedures.
    * Participates in assuring hospital compliance with Federal and State regulatory requirements.
    * Submit ideas to improve work flow and increase productivity of his/her team to the Executive Director and perform any other duties as assigned.
    * Demonstrated ability to provide leadership and direction to Clinical Documentation Department team members and coding specialists with relation to Clinical Documentation Issues.
    * Identify team development opportunities, perform management and evaluation tasks for all Clinical Documentation team members, oversee timekeeping duties, and assist in hiring of new employees.

  • Identify Clinical Documentation Integrity issues and through excellent communication with physicians, nurses, coding and other members of the health care team work independently to resolve such issues. Develop and present CDI Program reports for tracking and trending and employee productivity reports of CDI team to the Executive Director monthly. Proactively provides action plan(s) for any identifiable opportunities.
    * Extremely proficient in communicating clearly and effectively to all customers
    * Extremely proficient in computer usage, especially CDI Software, database and spreadsheet tools
    * High level of analysis, tracking and trending identification and problem-solving abilities

  • Actively lead meetings with clinical and non-clinical leadership at Wellstar facilities. Demonstrates the ability to determine the most appropriate format and scope for internal and external teams? deliverables, including the ability to create deliverables suitable for senior-level facility leadership and internal team members. Ability to identify and articulate project obstacles/issues and determine potential solutions while working collaboratively. Expresses self in a confident manner in individual and group settings.

  • Review and renewal of benchmarks and achievements. Ensure and communicate any changes in compliance with state and regulatory guidelines to Executive Director of CDI. Provide input to Executive Director of CDI for budgetary dollars, FTE's necessary to support business initiatives for Clinical Documentation Department's and future growth when needed.

  • Trust/Engagement (Mandatory Content)a. Builds a culture of trust and engagement as reflected in the Great Place to Work Trust Index Survey at a direct report, workgroup and hospital/entity level.
    *Holds leaders accountable for behaviors that create trust and engagement.
    *Performs all duties and responsibilities of this position in a manner that reflects the values of WellStar.
    *Maintains and strengthens relationships with physicians and assures their involvement in developing systems to assure the growth of the service and the cost-effective delivery of quality patient care in a manner that fosters *Patient and employee satisfaction.

  • Results Oriented Leadership (Mandatory Content)
    *Sets challenging and productive goals for team.
    *Holds team accountable for actions while providing leadership and motivation.
    *Provides resources and support,
    *Uses checkpoints and data to track progress, setting up system and processes to measure results.

  • Collaboration and Partnership (Mandatory Content)
    *Works collaboratively and as a team member with hospital leadership. Partners with Human Resources to achieve desired organizational culture, staffing and workforce metrics.
    *Fosters positive working relationships between staff and physicians across the Health System.
    *Fosters a culture that focuses on patient satisfaction, safety, customer service, staff participation, collaboration, motivation, and effective communication.

Required for All Jobs

  • Performs other duties as assigned
  • Complies with all WellStar Health System policies, standards of work, and code of conduct.


Required Minimum Education

  • Bachelor's Degree in nursing or Bachelor's Degree in a healthcare-related program 

Required Minimum Experience

  • Minimum 4 years working in an acute care setting as a Clinical Documentation Specialist (CDS) 

Preferred Experience

  • 2 years supervisory experience 
  • Prior experience of working as a CDI/Coding auditor 
  • Prior experience of working in inpatient case management or utilization review

Required Minimum Skills

  • Strong understanding of disease processes, clinical indications and treatments; and provider documentation requirements to reflect severity of illness, risk of mortality and support the diagnosis/procedures performed for accurate clinical coding and billing according to the rules of Medicare, Medicaid, and commercial payors
  • Familiarity with encoder and current working knowledge of Coding Clinic Guidelines and federal updates to DRG system (MS and APR)
  • Expert knowledge/experience in managing all aspects of Clinical Documentation Integrity, including CDI productivity, quality, education and training, compliance auditing, data analysis and trending, report management, performance improvement initiatives
  • Excellent communication skills, employing tact and effectiveness
  • Strong project management skills
  • Demonstrate effective communication skills and collaborates with medical staff, clinical departments, and key facility leadership team members
  • Ability to interpret, adapt, and apply guidelines, procedures, and continuous quality improvement initiatives
  • Excellent problem-solving skills, with the ability to recommend and implement practical and efficient solutions
  • Must have proficient computer skills in Microsoft Apps, such as Word, Excel and PowerPoint, as well as CDI technology tools required for the job functions
  • Must be comfortable with doing data analysis, and preparing and maintaining records and written reports
  • Drives optimal use of the CDI technology tool and reporting capabilities, and manages and holds CDI team to key performance indicators
  • Must possess skills to run a fiscally responsible program while ensuring constant improvement

Preferred  Minimum Skills

  • Epic and 3M360 experience 

Required Minimum License(s) and Certification(s)

Certified Documentation Improvement Practitioner (CDIP) by AHIMA or Certified Clinical Documentation Specialist (CCDS) by ACDIS

Additional Licenses and Certifications

  • It is expected that all RN's are licensed, knowledgeable and uphold the practice of nursing as outlined by the Scope of Practice and Code of Ethics Standards put forth by the American Nurses Association 
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