Job Description

Job SummaryJOB SUMMARY
At Houston Methodist, the Director Clinical Documentation Improvement/Integrity (CDI) Program position is responsible for developing and carrying out the vision and strategies of clinical documentation improvement activities throughout all campuses. The position ensures continuing education is developed and provided to not only the documentation improvement team members at each campus based on industry and individual needs but also to providers and physicians. In addition, the position evaluates the effectiveness of the program, identifies trends, recommends goals, implements strategies, and ensures quality so the program meets the organization's desired metrics. The position works closely with key stakeholders in Coding, Quality, Physician Champions, and others to ensure overall clinical documentation represents an accurate picture of the patient's hospital stay therefore confirming both internal and external reporting of information is accurate and complete.

The Director position responsibilities include overseeing the activities of the department staff, ensuring quality, productivity, functional excellence and efficiency to accomplish strategic and operational objectives. In addition, this position is accountable for employee engagement, adequate staffing levels, budget development and compliance, staffing decisions such as hiring and terminating employment, coaching and counseling employees on work related performance, and developing and implementing policies and procedures to ensure a safe and effective work environment. This position also ensures training, monitoring and operations initiatives are implemented which secure compliance with ethical and legal business practices and accreditation/regulatory/government regulations.

Requirements:

PRIMARY JOB RESPONSIBILITIES
Job responsibilities labeled EF capture those duties that are essential functions of the job.

PEOPLE - 20%
1. Directs, develops and implements strategic and operational/high level projects and processes either through independent/highly autonomous work or through the facilitation of work teams to enable the effective and efficient completion of objectives. (EF)
2. Oversees management of and ensures development for staff to meet overall objectives in terms of quality, service and cost effectiveness. Provides timely guidance and feedback to help others strengthen specific knowledge/skill areas needed to accomplish a task or solve a problem. Directs management responsibilities of selection, scheduling, supervision, retention, and evaluation of employees. (EF)
3. Meets or exceeds threshold goal for department turnover and/or system metrics on employee engagement indicators: action readiness score, tier level. (EF)
4. Provides leadership and communication to maintain a competent and engaged employee group by conducting regular department meetings to review policies and procedures and operational matters, rounding on all employees, completing performance appraisals, conducting new hire feedback sessions, coaching/corrective counseling, and providing recognition/commendations to achieve desired outcomes. (EF)
5. Identifies opportunities and takes action to build strategic relationships between one's area and other areas, teams, departments, and units to achieve business goals. Drives the promotion of teamwork within and between departments; participates and/or leads and facilitates department process improvements as needed. (EF)
6. Seeks evaluation from entity executive leadership to ensure system CDI is meeting the individual organization's goals and strategies. (EF)

SERVICE - 20%
1. Oversees department operations, designated projects, schedules and activities as needed to ensure that goals or objectives are accomplished within the prescribed time frame. Sets priorities and functional standards, giving direction to staff as necessary to ensure the best possible delivery of service and high customer/patient satisfaction. (EF)
2. Drives department service standards and activities to impact department and/or system score for patient/customer-based satisfaction, through role modeling and fostering accountability. Serves and actively participates on various entity committees as a voice for the department. (EF)

QUALITY/SAFETY - 20%
1. Ensures a safe and effective working environment; monitors and/or revises the department safety plan and/or any specific accreditation/regulatory required safety guidelines. Responsible for staff maintenance of credentials and competencies, per accrediting/ licensing agency and/or department guidelines as applicable. (EF)
2. Employs a proactive approach in the optimization of safe outcomes and information systems by monitoring and improving the department workflow and enhancing operations, using peer-to-peer accountability and identifying solutions via collaboration. Implements process improvements utilizing tools such as lean principles. Role models situational awareness, using teachable moments to improve safety. (EF)
3. Responsible for employee compliance to policies and procedures and performs associated actions upon non-compliance (i.e., licensure/certification compliance, focal point review requirements, disaster plan, in-services, influenza immunization, wage and hour, standard hours, timely termination submission, timely timecard approval, etc.). (EF)
4. Works collaboratively with Quality, Case Management, Coding, and others to ensure clinical documentation in the patient's medical record is complete and accurately represents the patient's stay so that internal and external reporting data truly represent the medical stay of the patient and care provided through documentation. (EF)
5. Establishes and oversees a quality assurance program to ensure the CDI team members are optimizing reviews and drafting compliant queries within regulatory guidelines. (EF)

FINANCE - 20%
1. Develops and manages department operational and capital budgets, approvals, and ongoing maintenance of the department(s), ensuring operation in a cost-effective manner. Proactively identifies and plans for capital needs related to current equipment and future department projects. Ensures staffing plans and schedules meet department needs that reflect understanding of the importance of cost-effectiveness. (EF)
2. Creates department strategies to achieve financial target and staffing needs, through optimizing productivity, supply/resource efficiency, minimizing incidental overtime and overtime percentage, and other areas according to department specifications. (EF)
3. Develops and monitor metrics unique to clinical documentation improvement so that the department supports the overall strategies and objectives of the organization. (EF)

GROWTH/INNOVATION - 20%
1. Identifies and implements innovative solutions for practice or workflow changes to improve department, entity or system operations by leading unit projects and/or other department/ system-directed activities. Proactively leads task forces and committees. May represent HM at assigned community or professional organization meetings. (EF)
2. Drives change initiatives, maintaining effectiveness when experiencing major changes in work responsibilities or environment; adjusts effectively to work within new work structures, processes, requirements or cultures. Partners effectively with stakeholders as appropriate. (EF)
3. Ensures own career discussions occur with appropriate management. Completes and updates the individual development plan (IDP) on an on-going basis. Conducts conversations with staff on their development and IDP. (EF)
4. Uses technology creatively to enhance services within the CDI department to drive efficiency, improve the customer experience, raise industry benchmarks, and become an early adopter of new ideas, applications, and/or processes. (EF)

This job description is not intended to be all inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.

Qualifications:

EDUCATION REQUIREMENTS
* Bachelor of Science in Nursing; may consider Medical School graduate where Western Medicine is practiced
* Master of Science in Nursing or other master's degree in a related field preferred

EXPERIENCE REQUIREMENTS
* Five years of Clinical Documentation Improvement/Integrity experience in a hospital setting
* Two years of management experience
* Utilization review or coding experience preferred

CERTIFICATIONS, LICENSES AND REGISTRATIONS REQUIRED
* For RN - Texas RN license or temporary TX RN license, should obtain permanent license within 90 days. Compact license acceptable according to current Board of Nursing requirements. Certified Clinical Documentation Specialist (CCDS) through the Association of Clinical Documentation Improvement Specialists, Certified Documentation Improvement Practitioner (CDIP) through the American Health Information Management Association, or Certified Coding Specialist (CCS) through the American Health Information Management Association preferred
* For Medical School graduate - Must have one of the following certifications:
* Certified Clinical Documentation Specialist (CCDS) through the Association of Clinical Documentation Improvement Specialists
* Certified Documentation Improvement Practitioner (CDIP) through the American Health Information Management Association
* Certified Coding Specialist (CCS) through the American Health Information Management Association