Supervisor, Clinical Documentation

Northwell Health

About The Position

Supervises and coordinates the staff and daily operations of the Clinical Documentation Improvement (CDI) department. Facilitates modifications to clinical documentation to ensure accurate depiction of the level of clinical services and patient severity through extensive concurrent interaction with physicians, nursing staff and other caregivers, case management, and medical records coding staff. The role oversees clinical documentation activities to ensure documentation accurately reflects the level of service rendered and severity of illness and complies with government and other regulations. It also develops and monitors strategic operating goals, objectives, and budgets; reports on operational performance and corrective actions; and develops direct reports while overseeing the development and management of indirect reports. All responsibilities noted are considered essential functions of the job under the Americans with Disabilities Act. Related duties not mentioned are not considered essential functions.

Requirements

Graduate from an accredited School of Nursing.
Current license to practice as a Registered Professional Nurse in New York State.
CCDS certification.
4–6 years of relevant experience.
0–2 years of leadership/management experience.

Responsibilities

Promotes Clinical Documentation department goals by selecting, motivating, and training capable team members.
Leads assigned Clinical Documentation team members by communicating and providing guidance toward achieving department objectives.
Supervises daily operations and oversees clinical documentation activities to ensure documentation accurately reflects the level of service rendered and severity of illness in compliance with government and other regulations for all patients.
Identifies admissions with specific diagnosis/DRG classifications or other categories of admissions.
Follows up on reviews conducted by CDS staff to evaluate whether issues discussed and clarified with physicians have been recorded in the patient’s chart.
Interacts with physicians regarding documentation appropriate to diagnosis and supporting appropriate levels of severity of illness and risk of mortality.
Develops and monitors strategic operating goals, objectives, and budget; reports operational performance, justification, and/or corrective action.
Develops and supervises direct reports and oversees the development and management of indirect reports.
Ensures compliance with government and agency regulations.
Performs related duties as required.