DescriptionPOSITION SUMMARY : The Clinical Documentation Supervisor is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation.
The CDI supervisor will provide support and expertise through comprehensive assessment and review of inpatient medical records.
The CDI Supervisor will facilitate accurate DRG assignment and obtain appropriate documentation through extensive interaction with physicians, ancillary healthcare providers, and health information management coding staff to ensure that reimbursement (reflecting the proper quality of care and appropriate reimbursement) is received for the level of services rendered to the patients.
Offers guidance and support to RN Clinical Documentation Specialists and assists the Director as needed. Coordinates meetings between CDI specialists and coders.
Provides medical director / physician advisor appropriate data reports for MD outreach due to lack of query response. This is a fulltime FTE of 40 hours a week.
FTE breakdown will consist of 60% concurrent assignment / chart review and 40% administrative time. RequirementsMINIMUM QUALIFICATIONS : Graduate from a Registered Nurse program;
current New Mexico RN license requiredEDUCATION : graduate from a registered nurse program; BSN preferredCERTIFICATION / LICENSES : Current New Mexico RN licenseSKILLS : Basic computer skills in word processing and spreadsheet utilizationExcellent written and verbal communication skillsProficient in computer use (desktop and / or laptop)Demonstrates basic knowledge regarding HIM coding standardsAnalytic skills necessary to accurately assess patient medical recordsExcellent interpersonal skills and ability to work on a teamAbility to be flexible and adjust to workload / assignment changes and interruptionsEXPERIENCE : Minimum of 5 years recent experience in healthcare required.
Prior experience in clinical documentation improvement, utilization review / management, discharge planning, quality management, case management or coding preferredNATURE OF SUPERVISION : -Responsible to : The Director of case management and The physician Advisor ENVIRONMENT : Bloodborne pathogenGeneral office environment and general hospital department / nursing unitsPHYSICAL REQUIREMENTS : Ability to walk and stand 80% of work time
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