RN - Supervisor of Clinical Documentation

Under the direction of the Clinical Documentation Integrity (CDI) Manager the Documentation Integrity Supervisor is responsible for the daily activities of CDI staff to ensure the associated duties are performed accurately and efficiently following all applicable rules and regulations. The supervisor will be responsible for meeting productivity guidelines. The supervisor will work collaboratively with service lines, medical staff, enterprise analytics staff and performance improvement staff regarding the timeliness and quality of queries. The supervisor will perform employee evaluations providing coaching and feedback regarding performance issues as well as work with the staff to identify and resolve process issues.

Licensedas a registered nurse (RN). A minimum of one year experience in a supervisory role in within the past five years in an acute care hospital setting required. Excellent critical thinking, time management and communication skills required. Proficiency in Microsoft Office suite and comfort working with data and/or learning new software required. Must be proficient in speaking, understanding, interpreting, and writing medical terminology. Must be comfortable interpreting and complying with federal/government regulations. At least one year of experience as a CDI or coding or auditing the acute care medical records within the past ten years desired.

Physical Requirements: Per organizational requirements

Responsible for monitoring and directing the daily activities of the CDI staff to ensure review functions are accurately completed in a timely manner at appropriate intervals using appropriate criteria. Fills role of staff revieweras needed in times of increased volume. Ensures the department is adequately staffed to fulfill departmental mission. 55%

  • Ensures claims for patients of payers using DRG reimbursement methodology are reviewed concurrently and when applicable, retroactively, to ensure all applicable diagnosis are captured by ICD-9 diagnosis codes.
  • Ensures the record of patients who expire are reviewed to accurately represent the severity of illness (SOI) and risk of mortality (ROM)
  • Works collaboratively with coding management.
  • Monitors bill hold for timely processing and release of CDI reviews.

Responsible for the monitoring of quality and proficiency of the CDI staff. Serves as a mentor to staff and provides performance feedback and coaching for success at regular intervals. – 25%

  • Performs audits on CDI staff performance per hospital policy/procedure and provides training as necessity
  • Evaluates the performance of supervised staff regarding the organization’s behavioral standards and performance of required job duties/responsibilities.
  • Ensures staff follow departmental policy/procedure for communicating their findings to the medical staff and applicable departments i.e., coding.
  • Ensures departmental tracking logs are kept current
  • Collects data for CDI metrics as needed

Serves as subject matter expert on CDI providing education to CDIstaff, medical staff, organization staff, etc. – 15%

  • Represents CDIat internal and external meetings as required
  • Serves on committees as required
  • Works collaboratively with other departments

Performs other CDI functions as appropriate. – 5%