The Clinical Documentation Department Manager is a Registered Nurse. Must oversee the review processes of patients of different ages and development in acute and chronic disease states. Must have proven leadership and management skills to promote effective and efficient review of physician documentation to support the patient’s level of care and develop action plans for improvement. Must have knowledge and job experience in management and supervision of personnel. Collaborates with interdisciplinary teams including, but not limited to, physicians, nurse practitioners, PA's, and the department managers for Revenue Integrity, Coding and Data Quality, Case Management and Health Information Management. Collaborates extensively with other members of the health care team to provide data and solution development processes. The Clinical Documentation Department Manager creates a support structure within each medical staff department for achieving clinical and operational excellence in relation to Clinical Documentation Improvement efforts. Is involved in the direction and education of all phases of the Clinical Documentation process and will be held accountable to work in a collegial manner with physicians, staff, and consultants. Requires skill and leadership in managing the day-to-day operations of the Clinical Documentation Department team of registered nurses and manages the staffing and training needs. Provides ongoing Clinical Documentation management program education for new staff, including new Clinical Documentation Registered Nurses, physicians, nurses and allied health professionals. Tracks and trends program compliance. Assumes responsibility for professional development by participating in workshops, conferences, and/or in-services and maintains appropriate records of participation.

Education/License/Certification:
BS in nursing and/or current CA Registered Nursing license. Masters in Health Administration, Nursing, Business Administration preferred.


Qualifications:
Clinical expertise and extensive knowledge of disease processes with clinical experience in an inpatient setting.

Preferred Qualifications:
Prefer experience with acute care, management and supervisory.

Duties:
Manage the Clinical Documentation Program Staff and coding specialists with relation to Clinical Documentation issues. Understanding of product development and continuous quality improvement knowledge and skills essential. Knowledge of insurance regulations and Medicare and Medicaid guidelines. Proficient in communicating clearly and effectively with multiple constituents. Proficient in negotiating complex systems to effect positive change. Proficient in computer usage. Knowledge of organizational policies and procedures, Skilled in identifying problems and recommending solutions. Skilled in preparing and maintaining records and written reports. Skilled in establishing and maintaining effective working relationships with physicians, hospital staff and vendors. Ability to interpret, adapt, and apply guidelines and procedures. Ability to analyze complex clinical scenarios and apply critical thinking. Knowledge of reimbursement systems. Knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation. Knowledge of treatment methodology, patient care assessment, data collection techniques.