Description

Are you a Registered Nurse (RN) with Clinical Documentation Improvement experience? Are you looking to move into a leadership position? UPMC is looking for a Manager of Clinical Documentation Improvement to join their team. This non-clinical position will oversee Clinical Documentation in the following UPMC hospitals: West Shore, Carlisle, Hanover, Memorial, and Lititz and the person will be required to visit each location. Certified Clinical Documentation Specialist (CCDS) Certification highly desired. Previous clinical documentation position experience or chart review experience is needed. A bachelor's degree in nursing is required.

Hours - Flexible 40 hours. Remote work capability at times. You pick your shift - any daytime hours you prefer 6am-2:30pm, 7a-3:30pm, 8a-4:30pm, 9a-5:30pm or any combination of. This schedule is flexible based on what works for you. 

As the manager, you will direct the activities of the Clinical Documentation Improvement (CDI) department, facilitate 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 health information coding staff.

Responsibilities:

• Assess productivity, quality, reimbursement, infection mortality rates
• Oversee nurses as they review charts to look for best documention
• Work with physicians and educate physicians of documention requirements
• Orient CDI staff
• Work closely with leadership team - attend weekly huddles, work with coding team, work closely with physicians
• Track workload, staff schedules, KRONOS schedule, case questions, and be a resource for your team
• Attend/lead multiple meetings such as CDI team huddles, educational meetings, utilization review
• Oversees compliance with government and agency regulations.
• Develops and monitors strategic operating goals, objectives and budget; and reports operational performance, justification and/or corrective action.
• Works with health, finance and physician groups to develop systems to facilitate complete documentation for data reporting purposes.
• Serves as a resource to Physicians/Case Manager and other key professional staff in matter relating to published DRG information.
• Monitors tracking response to CDI and trending completion of DRG worksheets via reports generated by Clinical Documentation Specialists (CDS).
• Interacts with physician regarding documentation appropriate to diagnosis and support appropriate levels of severity of illness and risk of mortality.
• Ensures follow 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.
• Ensures 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
• Oversees a system to identify admissions with specific diagnosis/DRG classifications or other categories of admissions. 
• Ensure chart review within 48-72 hours of admission to meet criteria. 
• Ensures periodic documentation review with cases that have a length of stay greater than 3 days.

Qualifications

• Bachelor's Degree in Nursing required
• Current license to practice as a Registered Professional Nurse in Pennsylvania required
• Previous experience in chart review is required.
• Minimum of seven (7) years of progressive experience in an acute care setting.
• Certified Clinical Documentation Specialist (CCDS) Certification desired
• Regulatory background and DRG reimbursement knowledge preferred.
• Ability to communicate effectively with physicians and other clinical professional staff.

Licensure, Certifications, and Clearances:

Certified Clinical Documentation Specialist (CCDS) Certification

Clearances must be dated within 90 days

• Act 33 with renewal
• Act 34 with renewal
• Act 73 FBI Clearance with renewal

UPMC is an Equal Opportunity Employer/Disability/Veteran

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