Supv Clinical Documentation / HIM Clinical Document Mgmt

Clinical Documentation Integrity Supervisor

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Position Summary:

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 regional/facility levels as assigned. The Clinical Documentation Supervisor will work in collaboration with the clinical documentation specialists (CDS), coding professionals, physicians, 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.

Position Responsibilities:

Key Areas of Responsibility

Program Oversight

• Accountability for program and regional 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 regional/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 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 teams ongoing feedback.
• Create relevant reports from Optum CAC CDI, Epic and facility data. Analyze data and recommend action planning to meet organizational and team goals.
• Disseminate reports and facility data to 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

Other Management

• 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 Quality and Education Specialist.
• Establishes and maintains performance expectations of their employees and evaluates performance 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.

Documentation Review

• 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 in development of query templates and smartphrases.
• Inputs review workflows, accurate data, and CDI query impact into Optum 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) and Patient Safety Indicators (PSI).
• Meets revenue cycle goals (Key Performance Indicators (KPIs) and Productivity Standards).
• Communicates with HIM coding staff to resolve discrepancies

Communication

• 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 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.

Other

• 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.

Projects

• Participates in other assignments and special projects, may lead projects as assigned.

Working Relationships:

Job Title of Individual(s) Reports To: Clinical Documentation Manager

# Workers Responsible For: Direct Reports: 2-25 In-Direct Reports: 0

Nature of Supervision: