Clinical Documentation Manager (CDI)

FT – M-F - Remote Work with onsite presence when needed.

Newark, DE

We are looking for a dynamic Clinical Documentation Manager with an active RN license to lead our Clinical Documentation Integrity Team.

This is a full-time position for a Clinical Documentation Manager at ChristianaCare Hospital. The Clinical Documentation Manager will oversee the daily operations of the clinical documentation improvement program, ensuring accurate and comprehensive clinical documentation that reflects the patient's clinical status and treatment. Responsibilities include collaborating with healthcare providers and coding professionals to enhance the quality of medical records, conducting documentation audits, providing education and training to the clinical team, monitoring compliance with documentation standards, and implementing process improvements to promote clinical documentation excellence.

SCOPE, PURPOSE, AND FREQUENCY OF CONTACTS:

Daily contact with Physicians, Clinical Documentation Specialists, Revenue Integrity, and Health Information Management.  Regular communication with the Director and Medical Director(s).

EDUCATION AND EXPERIENCE REQUIREMENTS:

• Active Delaware RN license or Compact Licensure. 
• Formal Clinical Training (RN) with professional licensure required
• Bachelor’s degree required; Three years’ experience in Clinical Documentation Integrity
• One year supervisory/management experience. 
• Certified Clinical Documentation Specialist (CCDS) through the Association of Clinical Documentation Improvement Specialists preferred
• Maintains required documented hours of relevant continuing education related to licensure requirements.
• An equivalent combination of education and experience may be substituted.

KNOWLEDGE, SKILL, AND ABILITY REQUIREMENTS:

• Knowledge of DRG payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures
• Working knowledge of computer software: Word, Access, Excel, PowerPoint, and clinical data packages.
• Knowledge of healthcare delivery and current clinical care.
• Knowledge of managing staff and processes.
• Skill in oral and written communication.
• Skill in initiation and maintenance of projects.
• Skill in analytical problem-solving techniques.
• Strong organizational skills.
• Ability to adjust to a changing work environment and demands necessitated by workload and program requirements.
• Ability to relate to others in a manner to gain confidence and establish support.
• Ability to maintain confidentiality in all aspects of related duties.