Clinical Documentation Specialist
1 week ago
Under the direction of the CDI (Clinical Documentation Improvement) Manager, the CDI Supervisor oversees day-to- day operations of the Clinical Documentation Program. The responsibility of the CDI Supervisor is to implement the Inpatient and Outpatient CDI Program operations and outcomes, and ensures practices are followed throughout the entire system. The CDI Supervisor will support all department efforts. The CDI Supervisor will be knowledgeable regarding the Centers for Medicare and Medicaid Services (CMS) Quality Initiatives, Hospital & physician Value Based Purchasing, Inpatient/Outpatient Perspective Payment Systems, Hierarchical Conditions Categories (HCC), Risk adjustment methodology, Meaningful Use, and AHIMA Query Guidelines. Duties include oversight of CDI workflow, data collection, analysis and reporting to ensure ongoing compliance with all CDI practices. In addition, the supervisor will be responsible to act as a liaison with internal and external parties on matters related to CDI. This position is considered a hybrid position requiring some on-site and some remote work.
Job Specific Functions:
1. Working closely with the CDI Manager, the Clinical Documentation Improvement (CDI) Supervisor is responsible for the monitoring and directing the daily activities of the Clinical Documentation Specialists (CDS). Assists with hiring & onboarding personnel based on department staffing plans. Promotes organizational climate of decision-making, autonomy and accountability.
2. Promotes an environment that supports excellence in clinical documentation improvement concepts by leading a collaborative process. Fosters collaborative partnerships with coding, Physician Advisors, medical staff and members of the organization.
3. Monitors CDS personnel for proficiency in clinical documentation concepts and standards. Oversees the workload with an emphasis on efficiency, timeliness and appropriate judgement for the defined scope of the CDI area. Ensures that Human Resource Department policies are followed including behavioral standards, staff competency, license and certification verifications, and Employee Health requirements are met.
4. Coordinates daily activities of the CDI staff to ensure overall quality and completeness of clinical documentation. This includes all clinical quality measures. Utilizing clinical knowledge, supervises CDS completing concurrent medical record reviews to assure all parameters are addressed. Focuses on enhancing the following objectives:
Ensures medical records are reviewed concurrently and retrospectively to preserve the integrity of the medical record to reflect the clinical picture of the patient stay.
Ensures mortality reviews are completed to accurately represent severity of illness (SOI) and risk of mortality (ROM).
Reviews Diagnostic Related Group (DRG) downgrade accounts for clinical validation and works with the denials team for appeals.
Monitors clinical quality measures for timely processing i.e. PSIs, HACs and core measures. Collect data on CDI metrics as needed.
5. Monitors the competence of the CDS staff for quality and proficiency. Serves as a mentor to staff and provides performance feedback and coaching for success at regular intervals.
Focuses on enhancing performance by the following objectives: Develop, maintain and update CDS training program.
Perform audit reviews of CDS performance and provide feedback/ training as necessary.
Ensure CDS follow department protocols for communicating queries with medical staff and coding. Ensure CDS follow query tracking workflows.
Identify potential performance improvement trends and variances.
Maintain current working knowledge of CDI best practices and regulatory changes. Ensures organization is ready for accreditation and state surveys
6. Represents the Health Information Management Department CDI program at internal and external meetings. Serves on committees as required and works collaborative with other departments, including but not limited to, Care Management, Utilization Review, and Revenue Cycle.
7. Facilitates and supports educational opportunities to provide innovative learning experiences for staff and create a culture of development.
8. Serves as a subject matter expert on CDI providing education to CDI staff and medical staff
Knowledge, Skills, and Abilities:
Requires knowledge of clinical documentation guidelines and compliance standards.
Requires intermediate computer skills including typing skills and use of Microsoft applications.
Prefer hands-on experience and knowledge of Encoder Software, Denial Software, EMR system and CDI chart review requirements, and other data base software.
Must have the ability to supervise and coordinate the work of subordinate personnel in a manner conducive to full performance and high morale.
Must be approachable, people oriented, and a good listener.
Must be able to communicate effectively and have excellent customer service skills.
Must be a change agent able to develop, implement and maintain policies and processes. Requires the ability to be a creative, independent thinker.
Must exhibit a high degree of professionalism, customer service, and enthusiasm. Must possess solid analytical and problem-solving skills.
Requires the ability to read, write and speak effectively in English.
Utilizes personal vehicle to routinely travel to assigned ambulatory clinic sites to provide formal and informal education to ambulatory clinic providers.
Education or equivalency:
Requires an associate degree in Nursing; or an equivalent combination of training and progressively responsible experience that will result in the required specialized knowledge and abilities to perform the assigned work. A Bachelor’s Degree in Nursing or Health Information Management or related field is preferred.
Experience:
Must have a minimum of five (5) years of clinical documentation related experience that demonstrates a solid understanding of the required knowledge, skills, and abilities.
Prior experience must include direct or indirect supervisory experience. Electronic Health Record experience is required. Prefer experience in providing classroom and/or on-site training.
Specialized training:
Required experience with encoder software, EMR electronic system, & Microsoft office products. Prefer formal training on Physician Query process.
Certification/licensure:
Requires a current, valid AZ RN license or valid compact RN licensure for current state of practice. Requires a Certified Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement Professional (CDIP)
Prefers a coding certification as a CCS/CCS-P/CIC/COC. Prefers a CRC certification.
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