Mgr Clinical Documentation

SUMMARY:

*This is a hybrid role*

The Manager Clinical Documentation reports to the Director of Clinical Documentation. Under general supervision and within Brown University Health policies and procedures, manages clinical documentation specialists in performing concurrent review and analysis of select medical records to ensure documentation accurately and completely reflects severity of patient illness, expected risk of mortality, and complexity of care of the patient. Assists the Director in developing, planning monitoring and adapting clinical documentation processes and educational programs across all Brown University Health.
Brown University Health employees are expected to successfully role model the organization’s values of Compassion, Accountability, Respect and Excellence, as these values guide our everyday actions with patients, customers and one another.
In addition to our values, all employees are expected to demonstrate the core Success Factors which tell us how we work together and how we get things done. The core Success Factors include:

Instill Trust and Value Differences
Patient and Community Focus and Collaborate

In addition, our leaders will demonstrate an aptitude for:

Ensure Accountability and Build Effective Teams
Drive Vision and Purpose and Optimize Work Processes

By applying core and leadership competencies, leaders help Brown University Health achieve its strategic goals.
RESPONSIBILITIES:

Manages day-to-day operations of Clinical Documentation Department and addresses staffing and training needs of clinical documentation specialists deployed to Brown University Health affiliated hospitals.
Collaborates with interdisciplinary teams including, but not limited to, physicians, nurse practitioners, physician assistants, nursing staff, and department managers for Health Information Management, Case Management, Corporate Compliance, Finance and Quality. Collaborates extensively with other members of health care team to provide data and solution development processes.
In collaboration with the Director, plans, implements and manages effective and efficient review of physician documentation to support documented patient's level of care. Develops related policies and procedures and ensures implementation and adherence to same. Provides input into development of budget to meet anticipated needs.
Interviews, selects, orients, assigns work and evaluates performance of subordinate professional and support staff. Communicates performance standards to support high quality of work.
Works in collegial manner with physicians, mid-level providers, staff and consultants to ensure on-going clinical documentation educational needs are addressed. Assists in the development and implementation of clinical documentation educational programs related to standards of effective clinical documentation for new staff, including clinical documentation specialists, physicians, nurses and allied health professionals.
Serves as advisor and resource to members of clinical documentation team in reviewing process of complex patients of different ages and development in acute and chronic disease states.
Provides ongoing feedback to clinical documentation integrity staff regarding quantity and quality of concurrent queries. Provides suggestions for additional queries. Addresses clinical documentation integrity staff questions regarding severity levels of specific cases as well as those from coding staff.
Develops and follows through on quality assurance plan to audit quality of clinical documentation integrity queries. Develops an action plan based on audit results and evaluates said plan.
Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation.
Oversees compliance with state and regulatory guidelines as well as practice briefs from American Health Information Management Association (AHIMA) and the Association of Clinical Documentation Improvement Specialists (ACDIS).
Maintains expert practitioner's knowledge of current standards and requirements for clinical documentation as defined by Centers for Medicare and Medicaid Services (CMS), Joint Commission, State of Rhode Island and other regulatory or certifying agencies identified by Brown University Health Corporate Compliance. Maintains and enhances professional self-development by participating in appropriate workshops, conferences, and/or in-services.
May perform duties of Clinical Documentation Specialist.
Performs other duties as assigned.

MINIMUM QUALIFICATIONS/EDUCATION:

• Bachelor's degree in nursing (BSN) required, Masters preferred with current licensure to practice as a registered nurse within the State of Rhode Island,.
• Master's degree preferred.
• Demonstrate knowledge and skills necessary to provide care to patients throughout the life span, with consideration of aging processes, human development stages and cultural patterns in each step of the care process.

QUALIFICATIONS-EXPERIENCE:

• Five to seven years of clinical documentation prior experience is required including CDI certification.
• Clinical experience in an acute care setting, demonstrating advanced clinical expertise and extensive knowledge of complex disease processes.
• Experience must demonstrate effective leadership, managerial and organizational skills, with highly developed oral and written communication skills to effectively direct staff and to discuss complex patient care issues with all levels of staff within and outside of the organization and to plan and implement clinical documentation educational programs.
• Must be familiar with activities associated with utilization review, case management and medical coding. Extensive knowledge of nursing care, clinical measurement tools, and clinical outcomes. Knowledge of care delivery documentation systems and related medical record documents.
• Effectiveness in identification and resolution of wide variety of issues affecting clinical documentation operations.
• Highly effective interpersonal skills to establish cooperative working relationship with diverse groups and individuals, the medical staff, and other healthcare disciplines.
• Proficient in computer usage, especially database and spreadsheet analysis.

SUPERVISION:
Supervisory responsibility for up to 30 FTEs.

Pay Range:

$112,070.40-$224,140.80

EEO Statement:

Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.

Location:

BHCS 15 LaSalle Square - 15 LaSalle Square Providence, Rhode Island 02903

Work Type:

M-F 8:00am-5:00pm

Work Shift:

Day

Daily Hours: 

8 hours

Driving Required:

No