MAIN FUNCTION:

The Supervisor of the Clinical Documentation Improvement is responsible for the oversight of the Clinical Documentation Specialists (CDS) and for ensuring that clinical documentation within the Arnot Health reflects the services and care provided to patients. The Supervisor will have access to physicians and clinical staff to participate in the assist in ensuring the ongoing documentation improvement effort is successful. Physician/Resident education is a key component of this role and the Supervisor will take an active role in initiating physician engagement and being accessible and visible. Is under the direction of the System Director HIM, CDI, and Archives.

WORK HOURS:

This position is a salaried position and covers the department when open – Monday through Friday.

DUTIES AND RESPONSIBILITIES:

2. Acts as an administrator for the CDI System (ie JATA, 3M, etc).

3. Co-chairs CDI Task Force.

4. Utilizes strategies such as data analysis and leads process improvement initiatives to implement changes in clinical documentation process.

5. Evaluates the success of the CDI process through system monitoring. Reports outcomes to Medical Records/Utilization Review Committee, CDI Task Force, and upon request.

6. Is responsible for the development and maintenance of resources for effective clinical practice through tools, educational programs, and audits.

7. In coordination with the Physician Advisor, responsible for denial response letters and the related activities of writing, processing, tracking, and monitoring the cycle of the denial including physician and staff education and/or awareness when necessary.

8. Provides for professional growth and staff development. Initiates and researches reference tools such as ACDIS for staff development.

9. Assesses learning needs and competencies of staff and collaborates to provide educational opportunities.

10. Conducts employee evaluations yearly in a timely and objective manner.

11. Works in collaboration with the System Director of HIM in staff selection and recruitment as well as progressive discipline and termination.

12. Oversees the documentation improvement efforts of the clinical documentation specialists including productivity, time management, query rates, query responses, and appropriate escalation.

13. Provides ongoing education to medical staff, residents, and medical students on documentation concerns. Maintain an open door policy to be accessible for ongoing education.

14. Tracks trends in documentation concerns and implementing corrective action.

15. Recommends and implements corrective actions when deficiencies are identified.

16. Measures the effectiveness of documentation tools.

17. Maintains hospital and department policies and procedures and ensures the CDS follow them.

18. Is responsible for attending all annual mandatory educational programs as required by position

19. It is understood that this job description lists typical duties for the classification and is not to be considered inclusive of all duties that may be assigned.

20. Employee understands and demonstrates the importance of satisfying the needs of the customer/patient by interacting with him/her in a friendly and caring way, being attentive to the customer’s needs, both psychologically and physically, and by taking the initiative to maintain communication with the customer in order to provide a secure and pleasant experience with the Medical Center.

21. Will also be responsible for all duties encompassed in Clinical Documentation Specialist job description.

EDUCATION, EXPERIENCE, SKILLS:

Minimum Qualifications: RN, BSN. A minimum of five years experience in nursing or other clinical area, coding, or utilization review/case management in an acute-care facility. Coding skills with experience in ICD-10-CM and working knowledge of the AHA Coding Clinic . The ability to establish cooperative working relationship with all levels of hospital personnel. Ability to work with minimum supervision. Organizational, administrative and prioritization skills. Ability to encourage and assist with team building. Effective written and verbal communications skills. Analytical skills. Proficient computer skills. Ability to maintain the confidentiality of sensitive information, both patients and employee. Must be familiar with applicable government health care reimbursement systems.

CARDIOPULMONARY RESUSCITATION (CPR) REQUIREMENTS:

No CPR required.

PHYSICAL DEMANDS:

Light physical effort. Routine office job.

EXPOSURE CATEGORY:

Category I Tasks that involve exposure to blood, body fluids or tissues.

**ADA Essential Functions