Clinical Documentation Improvement Supervisor

Conifer Health Solutions • Bryan, TX

316d

About The Position

The Clinical Documentation Improvement Supervisor is responsible for collecting and analyzing data to provide reports for hospital-wide use and to make recommendations as appropriate. This role involves participating in the planning, development, and implementation of the Clinical Documentation Management Program within the company. The supervisor educates members of the patient care team regarding documentation guidelines, including attending physicians, nursing, and other interdisciplinary team members. The position entails reviewing medical records to facilitate and obtain appropriate physician documentation for clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient, thereby improving the quality and completeness of clinical documentation.

Requirements

• Three or more years' experience in Clinical Documentation Improvement.
• Knowledge of Medicare Part A and familiarity with Medicare Part B.
• Knowledge of disease pathophysiology and drug utilization.
• Knowledge of MS-DRG classification and reimbursement structures.
• PC/Systems literate including the Internet and MS Office skills.
• Ability to apply coding conventions and official guidelines to health record documentation.
• Effective time management skills and ability to manage multiple priorities.
• Strong leadership and organizational skills.
• Effective written and verbal communication skills.
• Capacity to work independently in a virtual office setting.

Nice To Haves

• Graduate from a Nursing program, BSN, or graduate of Health Information Management (RHIT, RHIA preferred).
• One year supervisory experience or more.
• Active state Registered Nurse license or Certified Coding Specialist credential.
• CDIP or CCDS certification.
• RN, RHIT, RHIA, and CCS credentials.

Responsibilities

• Monitor and build the Clinical Documentation Improvement (CDI) team.
• Oversee and act as a resource for Clinical Documentation Improvement departments across Conifer Health.
• Test, interview, hire, and retain CDI staff.
• Lead meetings with team leads and CDI staff.
• Improve medical CMI.
• Oversee market CDI programs.
• Enforce company and departmental policies, practices, procedures, and work rules.
• Educate department and facility staff as needed.
• Communicate and complete CDI activities and coding issues for appropriate follow-up and resolution.
• Develop a collaborative CDI and Coding team.
• Lead ICD 10 impact initiatives and education for CDI staff.
• Perform analysis, identify trends, and validate compliance related to documentation clarity.
• Conduct initial medical records reviews of patient records within 24-48 hours of admission.
• Conduct follow-up reviews of patients every 2-3 days to support MS-DRG assignment.
• Formulate physician queries regarding missing or unclear documentation.
• Collaborate with case managers, nursing staff, and other ancillary staff regarding documentation.
• Stay current with coding guidelines and attend mandatory coding seminars.

Benefits

• Competitive benefits package.
• Resources and incentives to redefine healthcare services.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Ambulatory Health Care Services
• Education Level: Bachelor's degree