Clinical Transformation - Associate Medical Director, Clinical Documentation - Physician Advisor

The Associate Medical Director, Clinical Documentation, reports to the Medical Director of Utilization Management and will be a dyad partner with the Vice President of Health Information and Revenue Cycle.

The primary remit for this Associate Medical Director will be to foster complete, accurate and timely clinical documentation reflecting the care of the patients as well as supporting the business functions of the organization. Robust clinical documentation is essential to support optimal clinical care, appropriate coding and billing, and validated quality metrics for required reporting as well as identification of quality improvement opportunities. Serving as the liaison between the clinical documentation integrity/coding teams and the medical staff, the individual interacts with medical staff members to accurately portray the clinical presentation of hospitalized patients, in clinical documentation.

Job Summary:

The Associate Medical Director, Clinical Documentation, is a pivotal member of Cedars-Sinai’s leadership team, tasked with ensuring effective and efficient documentation by providing education and support to healthcare providers and partnering with the Health Information Department (HID) and Revenue Cycle leadership to create a seamless interface with clinicians.

Key responsibilities include the following:

1.       Support and enhance the organization’s clinical documentation practices.

·       Articulate the importance of correct disease reporting and ICD code capture.

·    Implement strategies to ensure timely and comprehensive documentation of active medical problems and severity of illness indicators as well as to substantiate medical necessity.

·    Collaborate closely with medical staff leadership, medical staff, and various clinical and non-clinical departments involved in clinical documentation.

·       Identify trends and work with medical staff and hospital administration to resolve issues.

·       Collaborate with other members of CDI leadership and staff on the development of coding and documentation guidelines.

·     Serves as a mentor, educator and resource for both CDI and Coding teams.  Collaborates to implement programs and optimize people, process, technology and training related to clinical documentation capture. 

2.       Support medical staff education, coaching, and collaboration to enhance clinical documentation.

·       Provide physician and surgeon coaching and education on clinical documentation improvement.

·   Function as a liaison between physicians and CDI/coders to streamline the query process and facilitate clarity on appropriate documentation to accurately reflect clinical and patient status.

·       Deliver education to departments and service lines on documentation guidelines.

·       Ensure physician accountability for efficient documentation of patient care.

·       Influences practicing clinicians to realize the impacts of quality documentation upon performance, reimbursement and patient care. 

3.       Implement innovative products to support best practices relative to clinical documentation.

·       Collaborate with Enterprise Information Specialists and 3M Engage One leadership to support best practices related to clinical documentation.

·       Assist with order set development and implementation.

·       Serve on the Health Information and Utilization Management Committee and drive clinical documentation decisions related to the EHR.

4.       Enhance compliance with Utilization Management policies at CSMC.

·     Conduct medical necessity reviews and make recommendations to facilitate discharge and appropriate use of alternative sites of care in occasions of the absence of the UM Medical Director.

·       Assist in length of stay management and substantiation of ongoing inpatient medical necessity.

·       Review medical records to perform quality and utilization oversight review.

·     Advise and collaborate with clinicians, revenue cycle and hospital leadership to enhance compliance with utilization management policies by providing documentation analysis, substantiating medical necessity, facilitating care progression, and clarifying queries.

5.       Enhance Health Information and Utilization Management departmental effectiveness.

·   Provides analysis of current practices and create tailored organizational, departmental, and physician-specific improvement opportunities. 

·       Leverages outcomes date to drive and improve strategic organizational performance and education strategy.

·   Demonstrates expertise in optimizing the electronic medical record to support ease, accuracy and completeness of clinical documentation capture.

·       Reviews complex clinical scenarios and provide guidance for optimal practice and documentation capture in support of appropriate patient status and code assignment.

·       Ensures that healthcare documentation complies with regulatory requirements and guidelines.

·   Builds relationships that foster trust and confidence. Demonstrates credibility and problem-solving skills. Mediates amongst departments, teams or individuals involved with a patient’s episode of care.

Our compensation philosophy:

We offer competitive total compensation that includes pay, benefits, and other incentive programs for our employees. The base pay range shown takes into account the wide range of factors that are considered in making compensation decisions including knowledge/skills; relevant experience and training; education/certifications/licensure; and other business and organizational factors.  This base pay range does not include our comprehensive benefits package and any incentive payments that may be applicable to this role.

Pay Range: $323,704-$443,174 Total Cash Compensation

Qualifications

REQUIRED:

•         Medical Degree (MD) from accredited medical school required.

•         Board Certified in Internal Medicine, General Surgery or related area of practice is required

•        Member of good standing in Medical Staff at CSMC (or ability to attain Medical Staff membership). 

•     Must have five (5) or more years of experience as a practicing physician and three (3) or more years of administrative experience improving a hospital/health system's efficiency, effectiveness, quality, and resource utilization (e.g., Utilization Management, Quality Improvement, etc.).

•         Unrestricted medical license in the state of California

•         Candidate must have three (3) or more years of supervising and developing the talents of others and experience in team building.

•         Candidate must possess knowledge and experience in Clinical Documentation Improvement and Quality Improvement.

•         Candidate must have demonstrated expertise in EHR systems and efficiency software programs with strong analytical, quantitative, and problem-solving skills.

•     Candidates must have an appreciation of the needs of full-time faculty physicians and physicians in private or group practice and have the flexibility to meet the needs of both groups.

•     Candidates must possess highly developed skills working effectively with a wide variety of stakeholders and constituencies who have strong interests and legitimate requirements.

•       Candidates must demonstrate personal confidence, presence, and professional demeanor with the ability to build rapport with the Medical Staff and CSMC leadership and to manage through conflicting points of views with stake holder teams during times of change and ambiguity.

•         Demonstrated superior interpersonal, communication and presentation skills with diverse audiences, in settings from one-on-one to large groups.

STRONGLY DESIRABLE SKILLS/DEMONSTRATED ATTRIBUTES:

·       Broad knowledge and thorough understanding of the trends and forces shaping health care delivery.

·       Understanding of coding classifications assignments, reimbursement methodologies, concepts of risk adjustment, severity of illness, risk of mortality, Case Mix Index (CMI), hospital acquired conditions (HACs), Hierarchical Condition Categories (HCCs), patient safety indicators (PSIs), core measure reporting, etc.

·       Demonstrate behaviors aligned with the organization's mission and values.

•       Drive results and produces outcomes.

·       Maintain confidentiality of patient care and operational business matters.

·       Adhere to professional and performance expectations set forth within the medical staff bylaws and hospital policies.

·       Participate in ongoing training and education related to the stated role and responsibilities.

·   Demonstrates competence in Continuous Quality Improvement processes including experience in measuring, assessing, and improving services and processes.

·       Demonstrates knowledge of the National Patient Safety Goals with the ability to apply each National Patient Safety Goal to his/her own responsibilities.

·       Demonstrates knowledge of the Medical Center's Patient Safety program and can describe the Medical Center's Significant Adverse Event process.

·       Demonstrates understanding and utilizes the chain of command as it relates to his/her own job.

·     Demonstrates understanding of the Medical Center's Culture of Safety and is committed to providing the highest quality patient care.