System Director, Clinical Documentation… at University of… · San…

System Director, Clinical Documentation Integrity

Location: San Francisco, CA, United States

Job Summary:

The System Director, Clinical Documentation Integrity (CDI) oversees best practices in clinical documentation to accurately represent patient complexity for all outcomes. The CDI team is part of the Department of Quality and Safety, the System Director reports to the Chief Quality Officer (CQO). The System Director is responsible for a cohesive clinical documentation strategy across the health system to ensure an accurate reflection of severity of illness, resources, and care for quality outcomes and to maximize reimbursement. Includes all inpatient clinical entities – Academic adult population; pediatrics - Benioff Children’s Hospitals; community setting - St Mary’s and St Francis Hospitals; and ambulatory for Medicare Advantage risk adjustment. The Director is a strategic dyad partner with four Medical Directors for the respective clinical entities - setting the vision and standards through the program’s foundation of structure-process-outcomes. The System Director develops partnerships with clinical services and multi-disciplinary teams to ensure precise documentation reflects complex care management. This includes partnering with clinical leaders for standard clinical definitions by service line experts templated into the EMR. In collaboration with the Medical Directors, the Director provides guidance and interpretation of outcomes to supports service line initiatives. The System Director collaborates with the health information management (HIM) leadership for Coding to ensure documentation maximizes DRG assignment for reimbursement and accuracy in quality outcomes. The CDI System Director closely follows team performance related to process and outcome metrics, provider engagement and supports a very significant ROI. The Director follows quality outcomes - case mix index (CMI), patient safety indicators (PSI), hospital acquired conditions (HAC), sepsis and mortality outcomes. The System Director is a strategic leader throughout the organization as the subject matter expert for the True North quality goals. The CDI System Director collaborates with other DOQS leaders and is a multi-disciplinary strategic partner for process improvement opportunities across the health system.

Department Overview:

Clinical Documentation Integrity (CDI) is a team within the Department of Quality & Safety that reviews provider documentation and facilitates accurate representation of patients treated across UCSF Health. Through collaborative relationships with clinical teams, CDI supports best practices in documentation improvement strategies with an emphasis on severity of illness, medical complexity and quality in the medical record. CDI closely follows case mix index, risk adjusted outcomes and mortality ratings.

% of time	Essential Function (Yes/No)	Key Responsibilities (To be completed by Supervisor)
50%		Leadership and Administration
	Yes	Leads the strategic planning of clinical documentation improvement (CDI) programs across the health system. Oversees the implementation of new initiatives, processes, and performance improvement plans as they relate to CDI.
	Yes	In collaboration with health system partners, builds a cohesive CDI strategy that includes the adult inpatient, pediatrics inpatient and ambulatory settings. Critical operational and clinical partners include leadership from: UCSF Medical Center, UCSF clinical departments, Benioff Children’s Hospital, Population Health and Revenue Cycle.
	Yes	Provides leadership and direction towards the development of clinical quality improvement programs in collaboration with physician leaders of focused clinical areas.
	Yes	Designs and oversees technical and administrative operations for clinical documentation as it relates to quality improvement activities. Accountable for the overall administrative planning and coordination of the staffing, fiscal and material resources. Assists with the development and implementation of new programs and policies.
	Yes	Directs and manages clinical documentation managers and supervisors in assigned areas, adheres to budgets, schedules, work plans, and performance requirements in order to achieve broadly stated objectives.
	Yes	Oversees policies, systems, processes, and staff training programs are in place to facilitate extensive record review with physicians, APPs, health information management professionals, and nursing staff.
	Yes	Cultivates relationships with physicians, clinicians, and coding professionals to introduce new workflows, processes and systems; oversees coordinated efforts to ensure accurate and timely clinical documentation in the medical record and accurate coding of Diagnosis Related Group (DRG)s. Resolves any conflicts that arise.
	Yes	In collaboration with EMR leadership to promote and support clinical documentation improvement efforts in organization-wide information technology initiatives, including business intelligence and the electronic medical record.
30%		Quality and Performance Management
	Yes	Represents clinical documentation across the health system on interdisciplinary committees. Advises senior management on a range of topics impacting the medical center, such as clinical documentation. May lead efforts with functional peer group managers, involving matters between other divisions.
		Provides strategic direction to assist in ensuring compliance with quality reporting requirements with Centers for Medicare and Medicaid Services (CMS), and State of California.
	Yes	Facilitates implementation and monitoring the reporting processes, response, and performance improvement activities. Leads quality improvement and educational activities.
	Yes	Owns and disseminates developed reports, analysis and recommendation for changes with both internal and externally. Utilizes reportable quality metrics for education with service-specific specialties to further enhance documentation
	Yes	Maintains active professional contacts through local, state, national and international associations.
	Yes	Performs other duties as assigned.
20%		Department and Staff
		Manages employee recruitment, performance evaluation and management, and staff development. Develops a strong culture of teamwork to ensure the quality of daily operations, effective interdepartmental collaborations, and the timely achievement of objectives.
		Encourages staff development opportunities. Ensures subordinate supervisors recognize and reinforce people's efforts and improvements. Provides for adequate training and assistance on new processes, systems and programs.
		Communicates policy and procedure changes to staff.
		Ensures current job descriptions and criteria-based performance evaluation standards for each position in the department.
100%		(To update total %, enter the amount of time in whole numbers (without the % symbol - e.g., 15, 20) then highlight the total sum (e.g., 1%) at the bottom of the column and press F9. The total sum should add up to 100%.)

Minimum Requirements:

• Bachelor’s degree in nursing or related health care field, or equivalent combination of education and experience.
• Minimum 8 years of related experience
• Demonstrated hospital management skills, with advanced expertise in clinical documentation and coding, database management, medical records processes and external regulations
• Proven understanding of conditions and diagnoses as they relate to reporting and reimbursement
• Comprehensive knowledge of relevant regulatory requirements, as well as related legislative, accreditation, licensing and compliance environments
• Strong ability to organize, manage multiple priorities, meet deadlines and assign work efficiently

Preferred Qualifications:

• Advanced degree in nursing or related health care field (e.g., MPH, MBA, etc,) or equivalent combination of education and experience
• RN: CA RN license
• CCDS certification
• Proven leadership, fiscal and operational management skills, with the ability to collaborate effectively with physicians, management and staff at all levels, and with external agencies
• Advanced knowledge of relevant hardware and software, as well as the specialty applications and healthcare information management systems used in clinical documentation, coding, data management, and reporting