Lead the development and implementation of MDS assessment processes to ensure accurate patient evaluations across inpatient, outpatient, and long-term care settings.
Oversee clinical documentation improvement initiatives to enhance the quality and completeness of medical records while ensuring compliance with HIPAA regulations.
Manage utilization review and utilization management activities to optimize patient care pathways, including discharge planning, hospice care, and emergency medicine services.
Collaborate with interdisciplinary teams—including nursing, case management, medical records, and coding specialists—to ensure precise ICD-10/ICD-9/ICD coding, CPT coding, DRG assignment, and accurate billing practices.
Supervise staff responsible for medical documentation review within electronic health record (EHR) systems such as Cerner, Athenahealth, eClinicalWorks, or other EMR platforms.
Ensure adherence to regulatory standards set by NCQA and Medicare for quality assurance and compliance audits.
Provide ongoing training on clinical documentation best practices, anatomy and physiology knowledge, medical terminology, and health information management protocols.
Work Hours
8:30a-5:00p
Skills
Extensive knowledge of Epic EMR systems along with proficiency in other EHR platforms such as Cerner or Athenahealth.
Strong understanding of managed care processes including Medicare regulations and utilization review procedures.
Critical care experience with familiarity in ICU protocols, Level I & II trauma centers, PICU (Pediatric Intensive Care Unit), or emergency medicine environments.
Proven expertise in medical coding (ICD-10/ICD-9/ICD coding), CPT coding, DRG assignment, and documentation review for inpatient and outpatient services.
Experience in hospital settings with acute care or nursing home environments; familiarity with discharge planning and hospice care is advantageous.
Knowledge of HIPAA compliance standards along with healthcare regulations related to medical records management.
Excellent leadership skills with the ability to manage multidisciplinary teams effectively while fostering a collaborative environment focused on quality improvement.
Strong communication skills tailored for training staff on complex clinical documentation requirements while maintaining clarity across departments. Join us in leading our clinical documentation initiatives to uphold the highest standards of patient care excellence while ensuring regulatory compliance within a compassionate community dedicated to aging with dignity.
