Clinical Document Improvement Director

ABOUT THE POSITION

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

Meet the Team!

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

Under general direction, plans, organizes and directs the Clinical Document Improvement (CDI) department; leads the development and execution of comprehensive CDI strategies to ensure accurate, complete and compliant clinical documentation across both inpatient and outpatient settings; provides leadership, mentorship and direction for all activities related to documentation improvement, coding accuracy and clinical data management; performs other related duties as required.

The Clinical Document Improvement Director is a single position management level classification and reports to an appropriate executive level position. This classification is characterized by managing departmental performance improvement initiatives, evaluate outcomes and ensure that all clinical documentation practices align with federal, state and local regulations, as well as industry best practices. This position will provide guidance on the resolution of complex documentation issues, establish key performance indicators (KPIs), and ensure that the department meets its objectives related to documentation accuracy, coding compliance and reimbursement optimization. The incumbent will work closely with senior leadership, physicians, nursing, coding, and quality assurance teams to foster a culture of documentation excellence.

This classification has been designated At-Will in accordance with the provisions provided under Article 6, Section 601E (8) of the County Management Resolution and serves at the pleasure of the Executive Director, RUHS.

This class has been deemed eligible for the Performance Recognition Plan as set forth under Article 3, Section 311 of the County Management Resolution. Program eligibility requires employees to be in a leadership position, manage other employees or programs, and have significant influence on the achievement of organizational objectives.

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.

SUPPLEMENTAL INFORMATION

Questions: For further information regarding this posting, contact the recruiter:

Veronica Zuno at

APPLICATION INFORMATION

Veteran's Preference

The County has a Veterans Preference Policy applicable to new hires. To qualify, upload a copy of your (or your spouse's) Member-4 Form DD-214 indicating dates of service, and a copy of your spouse's letter of disability (if applicable) with your application. For privacy reasons, it is recommended that you remove your social security information from the document(s). A Human Resources Representative will review the materials and determine if you qualify for veterans' preference. The Veterans Preference Policy, C-3 is available here:

Reasonable Accommodations

The County of Riverside is committed to providing reasonable accommodation to applicants as required by the Americans with Disabilities Act (ADA) and Fair Employment and Housing Act (FEHA). Qualified individuals with disabilities who need a reasonable accommodation during the application or selection process should contact the recruiter for the position noted above. For additional information and/or to obtain the appropriate form for requesting a reasonable accommodation, please visit the Disability Access Office web page located at:

Proof of Education

If using education to qualify or when requested by the recruiter, upload a copy of any license(s), official/unofficial transcript(s), degrees, and/or related employment documents to your NeoGov account at the time of application and before the closing date. Official or unofficial transcripts will be accepted.

If your education was completed outside of the United States, you will need to provide a copy of your Foreign Education Equivalency evaluation from a member of the National Association of Credential Evaluation Services (NACES) or Association of International Credential Evaluators, Inc. (AICE).

Equal Opportunity Employer

The County of Riverside is an Equal Opportunity Employer. It is the policy of the County of Riverside to provide equal employment opportunities for all qualified persons. All applicants will be considered without regard to race, color, religion, sex, national origin, age, disability, sexual orientation, gender, gender identity, gender expression, marital status, ancestry, medical condition (cancer and genetic characteristics), genetic information, or denial of medical and family care leave, or any other non-job-related factors.

Pre-Employment

All employment offers are contingent upon successful completion of pre-employment requirements including a criminal background investigation, which involves fingerprinting. (A felony or misdemeanor conviction may disqualify the applicant from County employment). A pre-employment physical examination and background check may be required.

Probationary Period

As an Approved Local Merit System, all County of Riverside employees, except those serving "At Will," are subject to the probationary period provisions as specified in the applicable Memorandum of Understanding, County Resolution, or Salary Ordinance. Temporary and Per Diem employees serve at the pleasure of the agency/department head.

General Information

Current County of Riverside and/or current employees of the hiring department may receive priority consideration. Qualified candidates may be considered for future County vacancies.

Job postings may close without notice based on application volume. Submit your complete application by the recruitment close date; no late applications are accepted. Ensure all relevant experience/education is reflected on your application/resume, as a failure to demonstrate position requirements may disqualify applicants. A description of job duties directly copied from the job classification or job posting will not be considered.

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