Manager, Quality Review

Interested in a career with both meaning and growth? Whether your abilities are in direct patient care or one of the many other areas of healthcare administration and support, everyone at Parkland works together to fulfill our mission: the health and well-being of individuals and communities entrusted to our care. By joining Parkland, you become part of a diverse healthcare legacy that's served our community for more than 125 years. Put your skills to work with us, seek opportunities to learn and join a talented team where patient care is more than a job. It's our passion.

Primary Purpose

Manages and coordinates Quality Reviews for both internal and external customers. Schedules reviews, establishes and monitors review time budgets, reviews staff work papers, works with Performance Improvement department as well as other customers to support meeting the goals of Parkland and data to ensure timely and thorough audits. Evaluates results of reviews to ensure timely and thorough reviews of Parkland's departments.

Minimum Specifications

Education

- Must have a Bachelor's degree in Business or Clinical field (i.e. Nursing, Health Information Management)

Experience

- Eight (8) years of previous Clinical Documentation Improvement, Clinical, Inpatient, Outpatient and Emergency Services ICD-9-CM, ICD-10-CM and CPT-4 coding reviews, provider education and/or audit experience in a healthcare environment to include two years of supervisory experience in a healthcare or compliance environment.

Equivalent Education and/or Experience

- May have an equivalent combination of education and experience in lieu of specified educational and experience requirements.

Certification/Registration/Licensure

- Because of the lag in SCCE, HCCA, NCRA, and AHIMA updating the status of certifications, current employees whose certification is granted through one of these associations are allowed up to seven (7) calendar days, after expiration, to provide proof of renewal. Although an additional seven (7) calendar days is allowed to provide proof of renewal, there cannot be a lapse in the certifications "active" status.

- Registered Health Information Administrator (RHIA), or - Registered Health Information Technician (RHIT), or

- Certified Coding Specialist (CCS), or

- Certified Healthcare Compliance (CHC)

Required Tests for Placement

Skills or Special Abilities

- Must have effective oral and written communication skills.

- Must be able to effectively supervise, educate, and train HIM staff.

- Must be proficient with Personal Computer, and spreadsheet, communications, and word processing software.

- Must be able to work independently with a strong communication & influencing skill set

- Must be able to define problems, collect data, establish facts, draw valid conclusions, and make recommendations for continuous improvement.

- Must be able to focus on the task at hand, eliminate redundancy, add value, standardize process, and sustain improvement

- Must be able to solve a wide range of practical problems and deal with a variety of concrete and complex variables.

Responsibilities

1. Clinical Pertinence
Monitors HIM Quality Review schedules and data, reviews audit work papers and reports, and prepares Quality analyst evaluations to ensure that the review focus is maintained and that reviews are performed in a timely and thorough manner.
Conducts quality reviews, as needed to provide expertise to the reviews of Parkland's departments.
Maintains and implements knowledge of all the rules, regulations, policies, procedures, guidelines, laws, etc. that impact or govern the HIM department and/or external customers to ensure that the department and Parkland are in compliance.
Maintains positive working relationships with all hospital departments to ensure that the responsibilities of the Department are performed in a thorough manner.
Identifies and analyzes the designs of jobs, work processes/flows for compliance of the Quality Review department as well as external customers, and implements appropriate changes to improve work effectiveness, productivity, and efficiency that support the overall goals of Parkland.
May serve on various interdisciplinary committees as assigned to provide expertise and representation from the HIM division.
Serves as representative of the HIM division as needed to provide expertise and representation in the absence of the Director.
Develops; implements and monitors annual goals and objectives as applicable for the Department, updating and reviewing departmental policies and procedures manuals that support the missions and objectives of the overall Quality Review function and Parkland.

2. Clinical Documentation Improvement (CDI) & Coding Documentation Education
Responsible to initiate, and oversee the clinical documentation improvement program activities to include productivity, quality, education and training, auditing, report management, DRG assurance, performance improvement initiatives and developing standardized practices, processes, policies and procedures.
Supports Director regarding clinical documentation improvement requirements to include any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, complexity of care rendered to all patients
Collaborates with coding, care management, quality, medical staff, nursing and other healthcare professionals to improve clinical documentation and improve quality outcomes.
Demonstrates the ability to effectively educate clinical documentation specialists, coders, physicians and other healthcare professionals regarding clinical documentation and care coordination criteria.
Monitors the performance of the CDI program to ensure alignment and support department and organizational goals as well as compliance in coding and billing practices with regulatory requirements.
Actively seeks to promote and help to maintain a professional team-oriented, service-conscious culture that contributes to the goals of the department and organization and reflects the values of the system.
Understands best practice Clinical Documentation Improvement technology solutions and effectively builds business cases for the implementation of such solutions.
Utilizes data and metrics to drive the development, implementation and monitoring of process improvement and standardization if clinical documentation improvement practices.
Effectively develops and manipulates large data sets, analyzes segments and data groups, to support the development and implementation of process and strategy changes.
Provides complete, accurate and timely reporting of Clinical Documentation data metrics to leadership.
Actively participates in regularly scheduled meetings providing appropriate data as needed.
Proactively escalates risks and issues to leadership, resulting in timely and effective resolution.
Utilizes tools to maintain awareness of client satisfaction; ensures effective and timely resolution of issues; drives continuous improvement in client satisfaction measures.
Proactively monitors performance; takes appropriate and timely action to escalate risks, issues, and drive resolution.
Maintains expert level knowledge of the processes related to Clinical Documentation Improvement; supports activities and initiatives that result in improved efficiency and financial performance.
Serves as representative of the HIM division as needed to provide expertise and representation in the absence of the Director.
Develops; implements and monitors annual goals and objectives for the Clinical Documentation Improvement (CDI) and Coding Documentation Education (CDE) department, updating and reviewing departmental policies and procedures manuals that support the missions and objectives of the overall CDI & CDE functions and Parkland.
Maintains and implements knowledge of all the rules, regulations, policies, procedures, guidelines, laws, etc. that impact or govern the HIM department and/or external customers to ensure that the department and Parkland are in compliance.
Identifies and analyzes the designs of jobs, work processes/flows for compliance of the Quality Review department as well as external customers, and implements appropriate changes to improve work effectiveness, productivity, and efficiency that support the overall goals of Parkland.

Coding Integrity

1. Develops and implements department-wide programs, including written materials and training aides, to ensure and promote the understanding of coding compliance issues, laws and regulations and consequences of non-compliance.
2. Conducts audits to monitor compliance with laws, regulations, guidelines, standards and procedures and to monitor accuracy of abstracted data elements. Incorporates focus areas published by regulatory agencies.
3. Develops and writes policies and procedures that establish standards for coding compliance and reporting processes, in cooperation with PHHS Compliance and Internal Audit Departments. Maintains the Coding Compliance Plan for PHHS Health Information Management Department.
4. Coordinates and monitors compliance with responses to Internal Audit Department recommendations related to coding.
5. Provides coding and medical record documentation guidance and in-service education to management, medical staff and other departments, as appropriate to ensure PHHS complies with all laws, rules and regulations.
6. Responsible for maintaining the coding and abstracting system, ensuring operations run effectively and within budget. Acts as resource for Coding/Reimbursement area software. Coordinates updates with Information Systems staff.
7. Monitors Epic Work queue activities and ensures maintenance levels are at established targets to expedite billing.
8. Develops; monitors and responds to a full range of quality indicators for all aspects of coding and medical record documentation.
9. Develops and maintains a system of management reporting that provides PHHS management with timely and relevant information on all aspects of coding compliance.
10. Works with Patient Billing and Collections to review and analyze rejected claims pertaining to diagnosis and procedure codes. Incorporates findings into coding audits and in-service programs. Coordinates and insures appropriate timely response to retrospective billing and third party requests for charts related to coding/billing inquiries.
11. Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact Health Information Management. Develops effective internal controls that promote adherence to applicable state/federal laws, and the program requirements of accreditation agencies and federal, state and private health plans. Seeks advice and guidance as necessary to ensure proper understanding.
12. Works with Manager of Record Processing, Inpatient Coding Supervisor and Outpatient Coding Supervisor to implement any corrective actions required as a result of monitoring or audit activity including re-audit, employee education, counseling, or employee termination.

Job Accountabilities
1. Identifies and analyzes the design of jobs, work processes, work flows, etc. for the area and implements appropriate changes to improve effectiveness, productivity, and efficiency that support the overall goals of the department and Parkland.
2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
3. Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and federal, state, and private health plans. Seeks advice and guidance as needed to ensure proper understanding.
4. Develops and monitors annual budgets that ensure the department has the necessary funds to carry out the goals and objectives that have been established for the department.
5. Develops, implements, monitors, and revises annual goals and objectives for the department that support the missions and objectives of Parkland.
6. Selects, trains, schedules, motivates, supervises, and evaluates employees making recommendations for disciplinary actions up to and including termination, to ensure maximum utilization of individual and group capabilities. Ensures that assigned employees receive opportunities to further their knowledge.