Director, Clinical Documentation Improvement – Quality and Safety Institute

Job title: Director, Clinical Documentation Improvement – Quality and Safety Institute

Company: Rochester Regional Health

Job description: Job Title: Director, CDIDepartment: Clinical Documentation Improvement
Location: Riedman Campus
Hours Per Week: 40
Schedule: Monday – Friday, 8am – 4:30pmSUMMARYThe Clinical Documentation Improvement Director provides a key role in advancing the long term success of the Clinical Documentation Improvement program at the system level. The Director is responsible for providing education, support, and mentoring at the system level as well as establishing and attaining system targets for performance metrics related to improved case-mix and quality measures. The Director provides daily oversight of Clinical Documentation Improvement Team across multiple facilities and is responsible for ensuring appropriate staffing levels in order to meet established targets and will work in association with the CDI clinicians, coders, and all members of the healthcare team to ensure accurate and timely clinical documentation in the medical record.RESPONSIBILITIES

• Responsible for CDI operations ensuring timeliness, accuracy, completeness, consistency, compliance and standards fulfillment as defined in RRH and HIM policies, guidelines and performance standards.
• Provides direct managerial oversight to CDI Team in management of CDI processes CDI projects, barriers and education work processes, to include quality reviews and educational classes.
• Maintains up-to-date knowledge of regulatory changes impacting coding requirements and ensures CDI staffs are appropriately educated.
• Responsible for systematic approaches that contribute to a quality health record, while maintaining strong regulatory and legal compliance, and high levels of customer service.
• Responsible for the development and management of strategy, specific goals, objectives, budgets and performance standards for the RRH CDI program.
• Responsible for implementing, developing and maintaining a CDI program.
• Serves as an educator for the CDI Team and other healthcare professionals/departments in the use of coding guidelines and proper documentation requirements as it relates to data quality management and reimbursement.
• Responsible for the recruitment, selection, orientation and retention process. Provides coaching, counseling, and mentoring as appropriate. Completes performance appraisals for team members according to system schedule.
• Coordinates and/or facilitates on-going CDI meetings and training.
• Analyzes Case Mix Index for trends, determine root cause and address as appropriate.
• Prepares statistical and narrative reports.
• Represents the HIM Department through participation in various system committees and work groups, including billing, revenue cycle, denials, and others as assigned.
• Ensure effective staffing levels by evaluating RRH volumes.
• Ensure effective scheduling of CDI team to ensure proper coverage.
• Demonstrate proven leadership and management skills to promote effective and efficient review of physician documentation and the medical record.
• Demonstrate knowledge and job experience in management and supervision of personnel, including team building and conflict resolution.
• Collaborate with interdisciplinary teams including, but not limited to Physician Advisors (Pad), physicians, nurse practitioners, PA’s, mid-level practitioners and the department managers for Revenue Integrity, Coding and Data Quality, Case Management and Health Information Management.
• Develops the direction and education of all phases of the Clinical Documentation Improvement process.
• Provide ongoing program education for new staff, including new Clinical Documentation Improvement Registered Nurses, physicians, nurses and allied health professionals.
• Tracks and trends program compliance to ensure adherence to all CMS regulations regarding DRG assignment.
• Assume responsibility for professional development through participation at workshops, conferences, and/or in-services and maintains appropriate records of participation.
• Develops performance targets for each facility and disseminate reports to appropriate administrative personnel indicating productivity and success of the CDI program.
• Demonstrates extensive knowledge of reimbursement systems (MS-DRG), as well as federal, state and payer-specific regulations and policies pertaining to documentation, coding and billing.
• Demonstrates advanced clinical expertise and extensive knowledge of complex disease processes in an inpatient setting.
• Exhibits excellent observation skills, analytical-critical thinking, problem solving, plus effective oral and written communication skills.
• Performs other duties as assigned.

REQUIRED QUALIFICATIONS

• Must obtain Certified Clinical Documentation Specialist (CCDS) within two years of hire.
• Minimum five years acute care experience required.
• RN (must be licensed in the state of New York), BSN, or other clinician with advanced clinical knowledge, including: MDs or international physicians; physician assistants; or, Nurse Practitioners.

PREFERRED QUALIFICATIONS

• Management/supervisory experience preferred.
• Experience with EPIC preferred.

EDUCATION: BSLICENSES / CERTIFICATIONS: RN – Registered Nurse – New York State Education Department (NYSED)New York State Education Department (NYSED)PHYSICAL REQUIREMENTS: S – Sedentary Work – Exerting up to 10 pounds of force occasionally Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements.Any physical requirements reported by a prospective employee and/or employee’s physician or delegate will be considered for accommodations.PAY RANGE: $105,000.00 – $135,000.00CITY: RochesterPOSTAL CODE: 14617The listed base pay range is a good faith representation of current potential base pay for a successful full time applicant. It may be modified in the future and eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.Rochester Regional Health is an Equal Opportunity/Affirmative Action Employer.
Minority/Female/Disability/Veterans by a prospective employee and/or employee’s Physician or delegate will be considered for accommodations.

Expected salary: $105000 – 135000 per year

Location: New York

Job date: Sat, 05 Jul 2025 02:05:37 GMT

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