Summary

This position manages the clinical documentation improvement program, identifying areas of focus for improvement opportunity through report analysis interpretation of process and operational reports, financial and compliance reports, and quality ratings reports. Assists with various associated operational matters including appropriate scheduling and coverage of reviews, query development and auditing, educating physicians, monitoring the program, and refining the process as needed to clarify documentation in records. Coordinates follow-up on unanswered queries during the patient stay, as needed, to obtain prompt response to open queries. Serves as a resource to physicians and administration regarding issues related to the appropriateness of inpatient DRG assignment. Works collaboratively with the CDI team to facilitate documentation within the medical record that supports patient's severity of illness and risk of mortality utilizing strong communication skills with physician, physician extender, case manager, utilization reviewer, nurse or other healthcare professionals, utilizing appropriate querying tools to capture needed documentation.

Job description

Position Description

This position manages the clinical documentation improvement program, identifying areas of focus for improvement opportunity through report analysis interpretation of process and operational reports, financial and compliance reports, and quality ratings reports. Assists with various associated operational matters including appropriate scheduling and coverage of reviews, query development and auditing, educating physicians, monitoring the program, and refining the process as needed to clarify documentation in records. Coordinates follow-up on unanswered queries during the patient stay, as needed, to obtain prompt response to open queries. Serves as a resource to physicians and administration regarding issues related to the appropriateness of inpatient DRG assignment. Works collaboratively with the CDI team to facilitate documentation within the medical record that supports patient's severity of illness and risk of mortality utilizing strong communication skills with physician, physician extender, case manager, utilization reviewer, nurse or other healthcare professionals, utilizing appropriate querying tools to capture needed documentation.

Duties

Manages the operations of the Clinical Documentation Improvement (CDI) program.
Manages departmental staff including day to day supervision, employee relations and staff development.
Functions as the super-user and trainer for the CDI program and all application software used by staff to code/assign working MS-DRG, APR-DRG, SOI, and ROM.
Serves as the lead educational resource for all internal customers on CDI program effectiveness and requirements related to compliant documentation for DRG revenue assurance, compliance and quality outcomes.
Oversees CDIS audits to ensure compliant and effective queries.
Will provide both the influence and guidance, as well as managing CDI team.
Performs other duties as assigned/required.

Requirements

Graduate of nursing program
BSN preferred
Minimum of 5 years recent clinical experience in an acute care setting
Critical Care or Medical/Surgical preferred
3-5 years experience with inpatient coding and DRG guidelines
Ability to work independently in a time-oriented environment
Working knowledge of Medicare reimbursement system and coding guidelines preferred
Excellent written and verbal communication skills required
Knowledge of age-specific needs and elements of disease processes and related procedures required
Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes
Computer literacy essential
Registered Nurse with current S.C. license
RHIA, RHIT or CCS preferred

Benefits

Employee Referral Bonus
Paid Time Off
Medical, Dental & Vision
Prescription Drug Plan
Tuition/Certification Reimbursement
Employee Recognition Program
Clinical Nursing Ladder
Student Loan Refinancing
401(k) Matching
Discounted Stock Plan
Career Development

Company overview

Universal Health Services, Inc. (UHS) is one of the nation's largest and most respected providers of hospital and healthcare services, operating as a Fortune 300 corporation headquartered in King of Prussia, Pennsylvania. Founded in 1979, UHS has grown into a major healthcare enterprise with approximately 99,000 employees and annual revenues exceeding $14 billion. The company operates through its subsidiaries, managing 29 acute care hospitals, 331 behavioral health facilities, and 60 outpatient and other facilities across 39 U.S. states, Washington D.C., Puerto Rico, and the United Kingdom. UHS provides comprehensive healthcare services including acute care, behavioral health treatment, cancer centers, and ambulatory surgical centers. The company's strategy focuses on building or acquiring high-quality hospitals in rapidly growing markets and investing in advanced medical equipment and skilled personnel to become the leading healthcare provider in each community it serves. UHS is publicly traded on the New York Stock Exchange (NYSE: UHS) and has established a strong reputation for delivering compassionate, high-quality care while maintaining financial stability and operational excellence.