Regional Director of Clinical Documentation Integrity | PAM Health Corporate

The Regional Director of Clinical Documentation Integrity (RDCDI) is responsible for the support of the CDI program objectives as related to securing a thorough complete and accurate patient health record throughout our rehabs in an effort to achieve the correct reimbursement for resource utilization the highest quality measures and outcomes superior communication between providers and ultimately high patient satisfaction and quality care. The position will work closely with the key executive leaders and hospital leadership to ensure documentation within the medical record is comprehensive and complete and to create a support structure for achieving clinical and operational excellence in relation to CDI efforts. The RDCDI will assume responsibility to develop and provide continuing education of the CDI process. The role is responsible for reporting CDI metrics and developing supporting plans to address adverse trends identified. The position reports to the Corporate Director of CDI.

Develops and manages the Clinical Documentation functions/activities at each of the assigned hospitals.

Acts as a subject matter expert for CDI within the organization and provides assistance with internal hospital initiatives as needed

Performance of initial reviews concurrent reviews and retrospective reviews (as appropriate) to ensure the CMG accurately reflects the principal diagnosis and comorbid conditions after study; Review of the working CMG and identification of conditions POA (present on admission) HAI HAC and potential CMG migrations.

Ensure capture of documentation to support the SOI/ROM and resource consumption associated with the care on a concurrent basis and provides ongoing guidance for assigned hospitals

Addresses CDI review opportunities to ensure the documentation is complete and accurate and provide education.

Analyze clinical information to identify areas within the medical record that are conflicting imprecise incomplete ambiguous inconsistent or illegible and queries on a concurrent basis to obtain clarification in the medical record in collaboration with hospital support

Utilizes a compliant query process per guidelines and policy when conducting all queries; both written and verbal

Monitor track trend and report of query rates as related to type response rates associates provider and outcomes

Collaborates with hospital staff and providers to promote complete and accurate clinical documentation and to correct negative data trends; acts as a consultant to key stakeholders when additional information is needed

Provides CDI education to providers clinical staff or departments one on one during staff meetings or departmental meetings as needed either remotely or on location.

Educates internal staff on clinical documentation and coding guidelines

II. Principle Duties

Maintains the highest level of customer service via courtesy compassion and positive communication

Promotes the Mission and Vision of PAM Health within the work environment and the community

Respects dignity and confidentiality by adherence to all applicable policies and procedures

Demonstrate compliance with all federal state and local laws; rules and government

Comply with the Employee Code of Conduct and all other Hospital Institutional Policies and Procedures

Education and Training: Graduation from a clinical program RN LPN RT etc and/or Bachelors of Science in Health Information Management or related degree Registered Health Information Administrator and/or Certified Coding Specialist certification.

Minimum Work Experience: 5 years acute care experience with recent management or supervisory experience.

Preferred Experience: CCDS or CDIP preferred. Must be willing to obtain CCDS or CDIP within first 2.5 years of employment

Required Knowledge Skills and Abilities:

Current licensure and/or certification

PAM Health is committed to being the most trusted source for post-acute services in every community it serves by utilizing experienced and dedicated staff to provide high quality patient care and customer service. With over 70 Long Term Acute Care and Rehabilitation hospitals and 16 Outpatient Clinics currently in operation across the country we are proud to offer services including comprehensive wound care aquatic therapy ventilator weaning amputation treatment pain management and much more.

Joining our PAMily allows you to work in a collaborative environment with colleagues and leadership with exposure to a variety of patient care levels. Aside from our competitive pay generous paid benefit time and excellent insurance options you will also have opportunities for professional growth through our Education Advancement Program.

We are excited to learn more about you and hope that you consider joining us on a shared mission to improve the lives of others by being an integral part of our We Care Program. Please take a moment to visit us online at a comprehensive look at how were able to positively impact our local communities.

PAM Healthdoes not discriminate and does not permit discrimination including without limitation bullying abuse or harassment on the basis of actual or perceived race color religion national origin ancestry age gender physical or mental disability sexual orientation gender identity or expression or HIV status or based on association with another person on account of that persons actual or perceived race color religion national origin ancestry age gender physical or mental disability sexual orientation gender identity or expression or HIV status.