Description

The Riverside University Health System (RUHS) – Medical Center seeks a Clinical Document Improvement Director to join our team.

The incumbent will provide strategic leadership and operational oversight of the Clinical Documentation Improvement team for the Medical Records Department. This role ensures that Clinical Documentation Improvement (CDI) goals align with organizational priorities and regulatory requirements while promoting the accuracy, quality, and completeness of clinical documentation. The most competitive candidates will possess clinical documentation improvement and management/leadership experience. 

Schedule: 9/80 M-F; 7 A.M. - 5 P.M. (Department may also provide option for 7:30 A.M. or 8 A.M. start time)

Location: Mission Grove:  7898 Mission Grove Parkway S., Riverside, CA 92508

To apply to this position, please click HERE

Meet the Team!

The Riverside University Health System is here for you when you or someone you love needs help to achieve and maintain a life of whole health wellness and recovery. Can you see yourself here?

EXAMPLES OF ESSENTIAL DUTIES:

• Oversee the CDI department's operations, including establishing short- and long-term goals, setting priorities and ensuring alignment with organizational objectives; provide strategic direction to CDI Supervisors and their teams.
• Manage change initiatives related to CDI processes, workflows and technologies; act as a change champion to facilitate the adoption of new systems and processes within the organization.
• Design, develop and implement CDI program strategies that improve the quality, accuracy and completeness of clinical documentation across all departments; ensure alignment with regulatory requirements, industry standards and payer guidelines.
• Supervise the CDI team and provide mentorship, coaching and professional development opportunities; evaluate staff performance and provide regular feedback to foster continuous improvement and growth within the team.
• Oversee the evaluation of clinical documentation to ensure compliance with applicable laws, regulations and best practices; drive continuous quality improvement initiatives to reduce errors, improve data accuracy and ensure proper reimbursement.
• Maintain accurate and comprehensive patient medical records through data analysis and by adhering to quality standards.
• Direct the collection, analysis and reporting of clinical documentation metrics and KPIs; utilize data to identify trends, monitor department performance and guide improvement efforts; present findings to senior leadership and other stakeholders.
• Develop and provide educational programs for clinical staff, CDI teams and leadership on documentation best practices, coding guidelines and emerging regulatory changes; ensure ongoing education to maintain high standards of documentation quality.
• Work with revenue cycle management teams to ensure accurate and timely coding and billing practices; educate healthcare providers and stakeholders on the impact of clinical documentation on reimbursement and ensure that the organization maximizes appropriate financial recovery.
• Collaborate with executives and departmental leadership to align CDI goals with the broader strategic objectives of the organization; participate in high-level planning and decision-making regarding documentation, coding, and reimbursement strategies.
• Collaborate with the quality department for quality-of-care initiatives and drive improvement for clinical measures and outcomes through efficient workflows and effective data capture.
• Develop and improve quality systems that cover monitoring and reporting for CDI operations and contract requirements. 
• Oversee relationships with external partners, including third-party vendors, contractors or consultants, to ensure the delivery of high-quality CDI services; manage contracts and vendor performance.

MINIMUM QUALIFICATIONS:

OPTION I

Education: Graduation from an accredited college or university with a bachelor's degree in nursing.

Experience: Four years as a Registered Nurse in an acute care hospital, which must include at least two years of supervisory experience in a healthcare setting.

License: Must possess and maintain a current valid license to practice as a Registered Nurse in the State of California.

OPTION II
Education: Graduation from an accredited college or university with a bachelor's degree in health information management or health information technology. (Additional qualifying experience may substitute for the required education on the basis of one year of full-time experience equaling 30 semester or 45 quarter units of the required education.)

Experience: Five years of professional coding and abstracting medical records in an acute care hospital, which must include at least two years of supervisory experience in a healthcare setting.

Certification: Possession of valid certification as a Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) issued by the American Health Information Management Association. 

OPTION III
Education: Completion of a Doctor of Medicine (MD) degree.

Experience: Two years performing clinical documentation improvement in a healthcare setting, which must include at least two years of supervisory experience in a healthcare setting.

Certification: Possession of valid certification as a Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) issued by the American Health Information Management Association. 

ALL OPTIONS
Knowledge of: Principles and practices of healthcare management, including leadership, fiscal oversight and compliance; clinical documentation standards, coding requirements and documentation guidelines, including ICD-10, CPT-4 and CMS-DRG assignment; regulatory and accreditation standards governing clinical documentation, including those from CMS, the Joint Commission and other governing bodies; revenue cycle management, including the relationship between accurate documentation, coding and reimbursement; advanced data analytics techniques, including statistical analysis and performance benchmarking, for monitoring CDI program outcomes; educational strategies for training and developing staff and clinical teams in documentation improvement.

Ability to: Provide visionary leadership and strategic direction for the CDI program; analyze complex clinical and operational issues and develop actionable solutions that improve documentation practices; effectively supervise and mentor a diverse team of CDI professionals, fostering a collaborative and performance-oriented culture; lead cross-functional teams and collaborate with senior leadership, physicians and other stakeholders to achieve documentation improvement goals; utilize data to assess program effectiveness, identify areas for improvement, and implement evidence-based solutions; communicate complex concepts and regulatory information clearly and effectively to diverse audiences, including clinical staff and leadership; manage projects, resources and budgets effectively to ensure the success of the CDI program.