Job Description

Supervises and coordinates the staff and daily operations of the Clinical Documentation Improvement (CDI) department. Facilitates modifications to clinical documentation to ensure accurate depiction of the level of clinical services and patient severity through extensive concurrent interaction with physicians, nursing staff and other caregivers, case management, and medical records coding staff.

Job Responsibility

• Promotes Clinical Documentation department goals by selecting, motivating, and training capable team members.
• Leads the activities of assigned Clinical Documentation team members by communicating and providing guidance toward achieving department objectives.
• Supervises daily operations and oversees the activities of clinical documentation, including modifications, accurately reflect the level of service rendered and severity of illness in compliance with government and other regulations for all patients.
• Identifies admissions with specific diagnosis/DRG classifications or other categories of admissions.
• Follows up reviews of clinical documentation are conducted by CDS staff to evaluate whether issues discussed and clarified with the physician have been recorded in the patient's chart.
• Interacts with physician regarding documentation appropriate to diagnosis and support appropriate levels of severity of illness and risk of mortality.
• Develops and monitors strategic operating goals, objectives and budget; reports operational performance, justification and/or corrective action.
• Develops and supervises direct reports; oversees the development and management of indirect reports.
• Ensures compliance with government and agency regulations.
• Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here, but considered related are not essential functions.

Job Qualification

• Graduate from an accredited School of Nursing required.
• Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed.
• 4-6 years of relevant experience and 0-2 years of leadership / management experience, required.

*Additional Salary Detail
The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future.When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).