[Remote] Supervisor, Clinical Documentation Integrity (Remote)

Note: The job is a remote job and is open to candidates in USA. Trinity Health is a healthcare organization seeking a Supervisor for their Clinical Documentation Integrity program. This role involves supervising daily operations, overseeing staff, and ensuring compliance with documentation standards to enhance clinical data quality and reimbursement processes.

Responsibilities

• Supervises daily operations of the CDI program for the Health Ministries (HMs) within their region
• Provides direct oversight of the Clinical Documentation Specialist and Clinical Documentation Integrity Coordinator
• Responsible for the daily assessments of current Clinical Documentation Specialist staffing levels and processes
• Ensures that defined goals are accomplished utilizing timely and compliant processes within the region
• Assists with policy and education development on the use of guidelines and proper documentation requirements
• Provides quality and productivity monitoring; coordinates and participates in performance improvement initiatives
• Provides training and education to clinical documentation specialists (CDS) to enhance clinical and coding skill sets and optimal utilization of the 3M CDI software
• Responsible for scheduling and work assignments for colleagues
• Works closely with Clinicians, Coding, Quality and Denials teams to facilitate documentation within the medical record
• Communicates effectively with staff to ensure defined regional and/or system goals are met
• Maintains current knowledge of the MS-DRG system, CCs/MCCs, impact on quality, risk of mortality, severity of illness and CMI as well as ICD-10 coding systems and the guidelines related to Clinical Documentation Integrity
• Facilitates appropriate clinical documentation to ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record
• Assists in overall quality, timeliness and completeness of the quality health record to ensure appropriate data, provider communication and quality outcomes
• Serves as a resource for appropriate clinical documentation
• Responsible for scheduling and staffing assignments for the Clinical Documentation Specialist and Clinical Documentation Integrity Coordinator positions
• Monitors time and attendance system along with maintaining attendance records
• Coordinates the work of external resources when used
• Facilitates training of all new CDS hires
• Assists the Regional Manager, Clinical Documentation Integrity, in the recruitment, retention and supervision of CDI staff
• Participates in the development of staff, including fostering teamwork, providing performance feedback, mentoring CDS and scheduling education
• Collaborates with the Regional Manager, Clinical Documentation Integrity, on competency assessments, performance evaluations, counseling and/or conflict resolution
• Communicates with and educates physicians and all other members of the healthcare team regarding clinical documentation and monitors provider participation
• Identifies learning opportunities for healthcare providers
• Ensures that direct reports communicate, educate and engage with physicians and other members of the healthcare team regarding clinical documentation
• Collaborates with coding staff to assure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care
• Ensures appropriate and accurate DRG assignment
• Resolves all discrepancies in a courteous manner
• Demonstrates a thorough understanding of the MS-DRG system, CCs/MCCs, impact on quality and CMI as well as ICD-10 coding systems and the guidelines related to Clinical Documentation Improvement
• Provides input for policy and procedure maintenance and development
• Assists with the collection, aggregation and analysis of data
• Collaborates in development and monitoring of performance to measure process outcomes, quality and productivity, and to ensure continual process improvements
• Ensures that direct reports remain current in coding guidelines and other regulatory directives that impact CDI performance
• Ensures all compliance and regulatory standards are met
• Ensures that direct reports perform clinical validation as part of the review process and remain current on CDI strategies
• Maintains superuser level skill set in the use of 3M/360 and leverages technology and system reporting to improve CDI team efficiency and effectiveness
• Monitors the CDI Dashboard and reporting to identify opportunities for improvement and areas of focus
• May perform CDI reviews to support program during high volume, short staffing periods
• Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Trinity Health Corporate Integrity Program, Code of Ethics, as well as other policies and procedures

Skills

• Bachelor's Degree in Health Information Management, Healthcare related field or Nursing or equivalent in experience
• Current Registered Nurse (RN) License
• Registered Health Information Administrator (RHIA)
• Registered Health Information Technician (RHIT)
• Certified Coding Specialists (CCS)
• Licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APN) or completion of medical school
• Minimum of five (5) years of current hospital clinical documentation integrity program experience is required
• Two (2) or more years of current experience supervising hospital clinical documentation integrity program is required
• Must have thorough knowledge of CMS regulations, coding guidelines and DRG reimbursement
• Demonstrated knowledge of state and federal Hospital Acquired Conditions (HAC) and other applicable quality indicator codes (i.e. PSI, PPI, etc.)
• Demonstrated, current expertise with 3M CDI Software
• Must possess strong analytical and critical thinking skills in order to detect and resolve problems related to clinical documentation integrity
• Demonstrated ability to effectively supervise diverse and geographically dispersed teams both onsite and remote
• Excellent interpersonal skills with ability to build collaborative working relationships with clinical staff, finance and compliance
• Must possess strong written and verbal communication skills to effectively supervise clinical documentation integrity activities and communicate with a wide-ranging audience
• Intermediate computer skills required, including working knowledge of and experience using MS Word, Excel, Outlook and PowerPoint
• Maintains professional attitude and ability to relate well with leadership, physicians, other care providers, colleagues and patients and others within the scope of the position
• Strong understanding of the Catholic health ministry in an evolving health care delivery system and changing reimbursement market
• Personal presence that is characterized by a sense of honesty, integrity, and caring as well as the ability to inspire and to motivate others to promote the philosophy, mission, vision, goals, and values of the Ministry
• Ability to work in a fast-paced, multi-customer environment, with conflicting needs
• Must possess the ability to comply with enterprise policies and procedures
• Certified Clinical Documentation Specialists (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred
• Working knowledge of Epic EMR preferred

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