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 hospitals 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 works 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 assumes responsibility to develop and provide continuing education of the CDI process. The role includes the responsibility for reporting CDI metrics and developing supporting plans to address adverse trends identified. The position reports to the Corporate Director of CDI.

Job Responsibilities 

• Must be willing to cross train to all service lines
• 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 DRG accurately reflects the principal diagnosis and comorbid conditions after study; Review of the working MS- DRG and identification of conditions POA (present on admission), HAI, HAC, and potential DRG 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
• Addresses CDI review 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 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 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 guideline.
• Attends Interdisciplinary Care Team meetings both remotely and on location to assess for CDI opportunities and educate on CDI activities expected during the meeting

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 (PAM) based in Enola, Pennsylvania, provides specialty healthcare services through more than 80 locations, as well as wound clinics and outpatient physical therapy locations, in 17 states. PAM Health is committed to providing high-quality patient care and outstanding customer service, coupled with the loyalty and dedication of highly trained staff, to be the most trusted source for post-acute services in every community it serves. Its mission is to serve people by providing compassionate, expert care, and to support recovery through education and research. 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 www.PAMHealth.com for a comprehensive look at how we're able to positively impact our local communities.

PAM Health does 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 person's actual or perceived race, color, religion, national origin, ancestry, age, gender, physical or mental disability, sexual orientation, gender identity or expression or HIV status.