Supv Clinical Documentation / HIM Clinical Document Mgmt

Hartford Healthcare • Farmington, CT

15d

About The Position

The Clinical Documentation Integrity Supervisor provides a key role in facilitating long-term success of Clinical Documentation Integrity (CDI) by providing day-to-day oversight of the program. They also represent and support CDI at the system/ facility levels. The Clinical Documentation Supervisor will work in collaboration with the clinical documentation specialists (CDS), coding professionals, providers, nursing staff and other patient care givers to ensure accurate and timely clinical documentation in the medical record. This role supports attaining appropriate DRGs, quality outcomes, and accurate coding based on sound clinical entries in the medical record. The Clinical Documentation Supervisor will provide education, support, and mentoring of the Clinical Documentation Specialists and ensure correct standard work, policies, procedures and guidelines are followed.

Requirements

• Bachelor degree or equivalent experience
• Registered Nurse (RN) with 3-5 years CDS experience
• RN and/or Certified Coding Specialist (CCS)
• Certified Clinical Documentation Specialist (CCDS) certification or Certified Clinical Documentation Professional (CDIP) within 1 year of hire
• Strong written and verbal communication skills.
• Solid analytical capabilities.
• Good organizational skills.
• Critical thinking, problem solving and deductive reasoning skills
• Excellent organizational, writing and interpersonal skills
• Understanding and support of clinical documentation integrity and strategies for improvement
• Knowledge of Pathophysiology and Disease Process
• Working knowledge of clinical informatics
• Extensive ability to understand and communicate the impact of CC/MCC’s, procedure codes, PSI/HAC, risk adjustment, and other variables on the assignment of the various DRG methodologies.
• Specialized understanding and knowledge of ICD-10-CM diagnosis and ICD-10-PCS procedure codes.
• Strong analytical capabilities.
• Excellent organizational skills, strong critical thinking, problem solving and deductive reasoning skills.
• Strong electronic medical record, encoder, CDI software, and/or Computer Assistant Coding (CAC) skills.
• Function independently
• Handle multiple priorities and increasing responsibility
• Able to travel between facilities and regions as needed
• Listen and acknowledge ideas and expressions of others attentively.
• Converse clearly using appropriate verbal and body language.
• Collaborate with others to achieve a common goal through mutual cooperation.
• Influence others for positive and productive outcomes.

Nice To Haves

• RN with 3-5 years CDS experience
• Previous management experience preferred

Responsibilities

• Accountability for program system success, achievement of annual improvement priorities and key performance indicators.
• Day-to-day oversight and resource to the clinical documentation program.
• Develop a collaborative and effective clinical documentation team.
• Responsible for system/facility accurate Case Mix Index (CMI), mortality observed to expected ratio (O\:E), capture of appropriate severity of illness (SOI) and risk of mortality (ROM), risk adjustment and hierarchal condition capture (HCC) codes, risk adjustment, and other high quality documentation outcome measures.
• Management of CDI standard work, workflows, policies, and guidelines consistent with System best practices.
• Assist with CDI /Coding meetings, and facilitate H3W work group meetings and activities as needed.
• Provide CDS team, CDI and Revenue Cycle Leadership, physician leaders, all providers, quality management team, and coding team ongoing feedback.
• Create relevant reports from Iodine or other CDI software, Epic and facility data. Analyze data and recommend action planning to meet organizational and team goals.
• Disseminate reports and facility data to physician leaders and Revenue Cycle leadership teams.
• Provide necessary feedback and conflict resolution to clinical documentation team
• Track program successes and ongoing opportunities, create and initiate action plans as indicated, report trends and concerns to CDI Manager
• Contributes to the efficient operation of the CDI department by establishing priorities, eliminating obstacles, and resolving problems.
• Provides ongoing feedback, coaching and mentoring, and assists in recruiting, developing and retaining Clinical Documentation Specialists (CDS). Ensures CDS’ continuing education and that requirements for job role are maintained (licensing, certification, other requirements).
• Oversees and manages orientation activities for new CDS in collaboration with CDI Manager of Quality and Education.
• Establishes and maintains performance expectations of their employees, evaluates performance and provides feedback in a timely manner to enable employees to be successful in their roles.
• Develops and implements HHC Performance Improvement activities as needed
• Conducts timely written Performance Evaluation and 1\:1 discussions under the direction of CDI Manager/Director.
• Provides CDI subject matter expert guidance to CDS team, coding, physician leadership, quality management, utilization management, all providers, and others as required.
• Assists in developing clinical documentation standard work, policies, procedures, workflows, and guidelines and educates staff.
• Facilitates CDI H3W work group as needed
• Assists manager with other tasks as necessary, provides coverage and back up when manager is absent.
• Day to day clinical documentation reviews and second level reviews as needed, initiate and complete compliant queries and follow-up reviews. Coaches and mentors CDS on CDI opportunities and compliant queries, assists with and provides education for the CDI team.
• Inputs review workflows, accurate data, and CDI query impact into Iodine or other CDI software and EPIC. Understands CDI query impact methodology and is able to identify discrepancies and coach CDI team to make needed corrections for query impact.
• Collaborates with coding leadership to determine appropriate Medicare Severity-Diagnosis Related Group (MS-DRG, APR-DRGs, etc.) assignment for compliance and reimbursement purposes.
• Works with Coding and Quality Management teams to appropriately identify compliant query opportunities regarding Hospital Acquired Conditions (HAC), Patient Safety Indicators (PSI), HCC’s, Vizient /Elixhauser variables and other risk adjustment variables.
• Meets revenue cycle goals (Key Performance Indicators (KPIs) and Productivity Standards).
• Communicates with HIM coding staff to resolve discrepancies.
• Ensures the appropriate dissemination and communication of all regulation, policy, and guideline changes to appropriate stakeholders.
• Participates in and represents CDI at local and system level by participating in regional and system interdisciplinary leadership meetings on quality, mortality and harm, and other HHC initiatives related to CDI.
• Presents education on topics related to clinical documentation integrity in all care settings to all service lines.
• Participates in and contributes to CDI Leadership and Coding/CDI Meetings.
• Works on general or special assignments and other duties and may lead specialized projects as assigned.
• Abides by The Ethical Standards for Clinical Documentation Improvement (CDI) Professionals as set forth by the American Health Information Management Association.
• Participates in other assignments and special projects, may lead projects as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees