Job Overview
We are seeking a dynamic and detail-oriented Clinical Documentation Integrity Manager to lead our clinical documentation improvement initiatives. In this pivotal role, you will oversee the accuracy, completeness, and quality of medical records across various healthcare settings. Your expertise will ensure compliance with healthcare regulations, optimize reimbursement processes, and support high-quality patient care. This position offers an exciting opportunity to influence clinical documentation standards and collaborate with multidisciplinary teams to enhance overall healthcare delivery.
Responsibilities
- Lead and manage the clinical documentation integrity program, ensuring adherence to industry standards such as NCQA and CMS guidelines.
- Collaborate with physicians, nurses, case managers, and health information management teams to improve documentation practices.
- Review medical records for completeness, accuracy, and compliance with regulatory requirements including HIPAA, Medicare, Medicaid, and state healthcare regulations.
- Utilize advanced electronic health record (EHR) systems such as Epic, Cerner, Athenahealth, eClinicalWorks, and others to facilitate documentation review and data analysis.
- Conduct ongoing education and training sessions for clinical staff on documentation standards, coding practices (CPT, ICD-9/10), and regulatory updates.
- Monitor key performance indicators related to clinical documentation integrity and implement process improvements accordingly.
- Stay current with evolving healthcare policies related to Medicare regulations, long-term care regulations, DRG assignments, utilization management, and hospital accreditation standards.
Qualifications
- Proven experience in clinical documentation improvement or medical records management within acute care hospitals or outpatient settings.
- Strong knowledge of medical terminology, physiology, anatomy, and nursing practices across various specialties including ICU, emergency medicine, pediatrics, hospice care, and long-term care.
- Familiarity with EMR/EHR systems such as Epic, Cerner, Athenahealth, eClinicalWorks; proficiency in Microsoft Office tools is preferred.
- In-depth understanding of coding systems including CPT coding (Current Procedural Terminology), ICD-9/10 coding (International Classification of Diseases), DRG assignment processes, and utilization review procedures.
- Experience working within managed care environments with knowledge of Medicare and Medicaid policies.
- Ability to interpret health regulation policies from CMS and state agencies while ensuring compliance with HIPAA and NCQA standards.
- Excellent communication skills for training staff and collaborating across departments; critical thinking skills for analyzing complex medical records.
- Relevant certifications such as Certified Coding Specialist (CCS), Certified Professional Medical Auditor (CPMA), or equivalent are highly desirable.
Join our team as a Clinical Documentation Integrity Manager to make a meaningful impact on patient care quality while advancing your career in a fast-paced healthcare environment!
Pay: $30.00 - $35.00 per hour
Benefits:
Work Location: In person
