Clinical Documentation Matters

Sample Job Description:  Clinical Documentation Manager

General description:

The manager of documentation and reimbursement is responsible for ensuring that clinical documentation within the health system accurately reflects the services and care provided to patients and is consistent with the seven criteria for high quality clinical documentation.  The manager acts as a coordinator of physician clinical documentation, coding and reimbursement processes in working towards agreed upon quality and productivity targets for all services in the system.

Experience:

The successful candidate should:

1. Have a minimum of 5 years management experience in clinical documentation 
2. Practices, health information, case management or related healthcare discipline
3. Be familiar with all government health care reimbursement systems
4. Have experience working collaboratively with diverse groups in a health care environment 
5. Be successful in interacting effectively with physicians
6. Possess excellent speaking, writing and teaching skills
7. Have the ability to analyze large amounts of data to identify trends    

Education:

1. Bachelors degree in nursing, health information management or equivalent; master’s preferred
2. Current certification or licensure preferred

Specific Responsibilities:

A.  Interdisciplinary

The manager of documentation and reimbursement functions primarily as an interdisciplinary manager focusing primarily on ensuring physician documentation is complete, accurate and representative of the care provided to the system’s patients.  To that end, the manager will have access to physicians and clinical staff to participate in and assist in ensuring the ongoing documentation improvement effort is successful. The manager will report directly to the VP of Clinical Affairs. 

The manager will:

1. Coordinate the activities of the Documentation Improvement Committee
2. Ensure that the Documentation Improvement Committee is continuously used primarily as a vehicle to promote documentation improvement for accurate reimbursement on an ongoing basis.
3. Oversee the documentation improvement efforts of clinical documentation specialists, case managers and related clinical staff
4. Provide ongoing education to medical staff on documentation concerns
5. Work with finance department on continuous case mix modeling and assessment
6. Participate in the rejections and claims review process with patient accounting  to ensure both compliance and accurate reimbursement
7. Track trends in documentation concerns and implementing corrective action
8. Direct coding activities to ensure accurate, consistent and compliant coding for all services   
9. Create and update documentation tools on an ongoing basis

B.  Inpatient Services

1. Track case mix through both retrospective and concurrent means
2. Provide feedback to clinical documentation specialists, case managers, coders, physicians and other clinicians involved in the documentation improvement effort
3. Recommend and implement corrective actions when deficiencies are identified

C.  Outpatient Services

1. Design a case mix tracking system for APCs
2. Implement a documentation improvement program for outpatient services
3. Recommend and implement corrective actions when deficiencies are  
   identified  

D.  Physician Services

1. Design a documentation proficiency tracking system for system-based pro- fee  billing & coding for physician employees
2. Implement a documentation improvement program for pro-fee billing and coding
3. Recommend and implement corrective actions when deficiencies are identified

E. Benchmarks

1. Measure the effectiveness of documentation tools
2. Trend and quantify the effectiveness of coding
3. Evaluate the success of concurrent documentation improvement on an
   ongoing basis