Manager, CDI and Auditing Services

Job Description

Description

Become part of an inclusive organization with over 40,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve.

Summary:

• The CDI Manager will be responsible for managing clinical documentation functions and overseeing the administrative responsibilities for staff, daily assignment of cases for the clinical documentation staff. Provides the necessary leadership to achieve the objectives of the Health Information Services Department and the hospital are met. Must plan, develop, and manage efficient and effective processes for CDI and Clinical Auditing activities. Services provided must meet the medical, administrative, legal, ethical, regulatory and institutional requirements utilized in the health care delivery system at UNC Health Lenoir. Will serve as the first-level resource for the Clinical Documentation team of registered nurses in addition to performing the functions of a Clinical Documentation Improvement Specialist (CDIS) as needed.

Responsibilities:

1. Manager Responsibilities: Provides leadership for staff with training, mentoring, appraising work performance, making personnel decisions, performs quality and compliance reviews, and provides regulatory guidance, work distribution and monitoring of issues for the hospital.

a. Manages CDI workflow for productivity, quality, and accuracy.

1. 2. Provides ongoing education to CDI staff.
   3. Recognize and facilitate implementations when necessary to achieve benchmark departmental and system metrics.
   4. Works cohesively with Coding manager, and HIS Director.
   5. Resource for reconciliation with Coding department and query escalation.

1. 5. • Performs ongoing audits and feedback to staff.
      • Serves as resource for mentoring and training CDI staff.
      • Track and trend data from CDIS reporting software.
      • Initiates Performance Improvement when necessary.

2. Financial Responsibility: Develops comprehensive budgets that reflect the needs of CDI based on external and internal environments and the application of cost-effective management. Monitors budget and reports variances in designated software. As needed, determines and develops (annually) a capital budget for administrative approval.

2. 0. Project needs and recommend budget funds in accordance with the hospital’s mission, vision and values.
   1. Manages area of responsibility in a cost-effective manner by utilizing maximum human resources and continuously reevaluating the manner in which services are delivered.
   2. Conducts operations with budgetary constraints.

3. Documentation Improvement:

a. Concurrently reviews clinical documentation and facilitates modifications, as needed, to ensure that documentation accurately reflects the reason for admission, intensity of service rendered and medical necessity, risk of mortality, and conditions present on admission for all patients, in compliance with government and other regulations. Provides education to physicians on relevant coding guidelines which impact mortality and severity classifications.

b. Notifies the attending physician or other disciplines promptly of queries requiring clarification, with a preference for face-to-face communication when practical. Conducts follow-up reviews to ensure points of clarification have been addressed/recorded in the medical record.

c. Appropriately prioritizes and assigns work to ensure compliance with requirements.

d. Solicits clarification from physician on any areas within the record in which further specificity is needed in the documentation. Educates physicians on documentation requirements through coding tips, face to face conversations and educational sessions. 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.

e. Collaborate with care management to effect change in documentation.

3. 0. Serves on Coding/CDI Team to review, analyze data and resolve coding discrepancies.

4. Student Education:

4. 0. Works with the two-year Health Information programs to provide a successful educational partnership for students during their clinical affiliations. Provides the affiliation experiences and activities required by student assignments to meet the goals and objectives of all parties.
   1. • To be based on feedback from the program’s clinical supervisors.

5. Clinical Audit Activities: Coordinates organizational activities to ensure compliance with RAC and External Agency program initiatives.

5. 0. Follows all RAC/Outside Agency activity to closure.
   1. Assists in the evaluation of charts reviewed by RAC. Reports to Health Information Services Director and Administration on denials or the likelihood of denial; dollar amount of accounts; any identified documentation issues and overall status of the Audit program.
   2. Identifies accounts eligible for appeal.
   3. Administers the audit appeal process.
   4. Follows appeal and denial process through all levels of appeal until a resolution is made and reports this progress quarterly to Medical Record Committee, Medical Staff and Administration.
   5. Works with Patient Financial Services to reconcile repayments and recoupments.
   6. Maintains open communication regarding RAC/Outside Agency activities with:
   7. • Administration/CFO
      • HIM/Release of Information
      • Patient Financial Services
      • Case Management/Physician Advisor Group
      • RAC's/CMS
      • Corporate Compliance
      • Ancillary departments as needed.
   8. Identifies barriers, evaluates and reports risk and develops workflow and process redesign if necessary to reduce and/or eliminate denials.
   9. Communicates with RAC, Fiscal Intermediary, Physician Advisor Group and other relevant entities when necessary to ensure smooth workflow.
   10. Identifies issues and initiates/participates in process changes.
   11. Utilizes critical thinking skills.
   12. Facilitates direction for more efficient and effective resource utilization.
   13. Serves as primary audit education resource for hospital staff, hospital leadership, medical staff and physician office staff.
   14. • Assists with learning needs of staff.
       • Participates in job-related seminars and in-services.
       • Serves on hospital committees addressing RAC and outside agencies.
       • Promotes education and implementation of process changes.
       • Provides and identifies appropriate resources to meet education needs of staff, physician or governmental agency.
   15. Coordinates Audit Denial Committee.
   16. Provides reports to hospital and medical staff committees as appropriate.
   17. Maintains accurate and thorough policies and procedures for the audit program.
   18. Performs chart audits, analyzing the clinical record and claim for documentation, and providing appropriate follow up.
   19. Analyzes audit and RAC/Outside Agency findings.
   20. Writes appeal with input from appropriate financial and coding personnel and/or medical staff, as appropriate.
   21. Adheres to required timeliness for filing appeals.
   22. Tracks and measures effectiveness of appeals.
   23. Timely communication with all affected entities involved in the audit process.
   24. Disseminates relevant information on any changes or updates to the permanent RAC program to appropriate parties.
   25. Communicates and confers with members of the health care team as needed to adequately respond to RAC or other outside agency denials.
   26. Identifies and follows through with strategies to improve processes.
   27. Problem solving skills are utilized to resolve issues and concerns.
   28. Keeps interdisciplinary team up to date regarding process changes.
   29. Updates all relevant personnel on RAC initiatives, changes in regulations, and findings from record reviews which affect department processes.
   30. Provides customers with appropriate resources to meet individual/organizational needs.
   31. Physicians, leadership, staff are educated regarding governmental regulations and other regulatory updates.
   32. Manages and coordinates all audit related system and software implementations and updates.
   33. Develops and maintains organization policies and procedures as needed in response to audit issues.

Other information:

• EDUCATION
• • B.S. in Nursing or Associate Degree in Nursing required with current license in state of NC.
• EXPERIENCE
• • Three years’ experience in ICD-10-CM and CPT coding in an acute care setting with a strong DRG background preferred. Knowledge of coding, regulatory and TJC guidelines with a strong clinical background preferred.
• LICENSURE/REGISTRATION/CERTIFICATION
• • RN or BSN required. CDIP or CCDS credential preferred and expected after two years of employment.

Job Details

Legal Employer: Lenoir Health

Entity: UNC Lenoir Health Care

Organization Unit: CDI

Work Type: Full Time

Standard Hours Per Week: 1.00

Work Schedule: Day Job

Location of Job: LENOIR MEM

Exempt From Overtime: Exempt: Yes