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:
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 Manager 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 Manager collaborates with providers and HIS 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. Compiles and documents chart findings in CDI software on a daily basis. Communicates with and educates members of the patient care team (physicians, advanced practice providers, patient resource managers, and case management) on an ongoing basis. Participates in select committees and provides education programs as necessary. Maintains documentation regarding results of audit activity and shares those with staff and management as necessary.

Other information:
Qualifications

EDUCATION REQUIREMENTS

• B.S. in Nursing or Associate Degree in Nursing required with current license in state of NC.

• 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.

• RN or BSN required. CDIP or CCDS credential preferred and expected after two years of employment.

• Critical reasoning skills in clinical decision making, problem solving and ability to interpret data.
• Flexible, positive and clear interpersonal and communication skills with the ability to provide information in a collaborative manner with physicians and other staff.
• Intermediate to advanced knowledge of computer systems Microsoft Office (Word, Excel, PowerPoint) experience required.
• Developed knowledge of anatomy, physiology and medical terminology, coding and reporting guidelines and ability to apply same.

• Mix of general office setting with clinical exposure requiring organizational skills to manage multiple projects and priorities.
• Some exposure to radiation from computer monitor.
• Primary equipment used: Computer, Printer, Copier, Telephone, Facsimile Machine

• Standing, squatting and carrying laptop and medical records.
• Talking on the phone and hearing well.
• Handling/fingering/feeling papers.
• Reads medical records and views computer monitor frequently.

Job Details

Legal Employer: Lenoir Health

Entity: UNC Lenoir Health Care

Organization Unit: CDI

Work Type: Full Time

Standard Hours Per Week: 40.00

Work Assignment Type: Onsite

Work Schedule: Day Job

Location of Job: LENOIR MEM

Exempt From Overtime: Exempt: Yes