Riverside University Health System-Medical Center is seeking a Clinical Documentation Improvement Supervisor for the Medical Records Department.The most competitive candidates will have significant CDI experience and be familiar with EPIC and 3M Clinical Documentation Integrity Services. At least one certification as a Certified Coding Specialist (CCS), Registered Health Information Technician OR Registered Health Information Administrator issued by the American Health Information Management Association is strongly preferred.
Under direction, the incumbent supervises, plans, directs, and coordinates the operations of the Clinical Document Improvement (CDI) department; assures compliance to conduct complex and difficult research and analytical studies involving the operations and programs of the department served; makes recommendations for the development, implementation and improvement of departmental operations, services, and programs; performs other related duties as required.
The Clinical Document Improvement Supervisor is the supervisory level classification in the Clinical Document Improvement series, performing the full range of supervisory duties. Incumbents will coordinate and organize the CDI for both inpatient and outpatient services, facilitate physician documentation, denials, and coding, and collaborate with physicians, directors, providers, and other healthcare team members to make improvements that result in accurate, comprehensive documentation that reflects completely, the clinical treatment, decision, and diagnoses for the patient.
Incumbents may participate in the employee selection process, training, coaching and mentoring of employees.
Meet the Team!Riverside University Health System-Medical Center consistently receives national recognition for its progressive and innovative care, as well as being known as one of the top employers in the region. The 439-bed Medical Center is a designated Stroke Center, Level II Trauma Center, and the only Pediatric ICU in the region. For more information on RUHS-Medical Center, please visit www.ruhealth.org.
For questions regarding this recruitment contact the recruiter, Angela Levinson:alevinson@rivco.org / 951-955-5562- Plan, assign and direct the work of a unit of Clinical Documentation Improvement Specialists.
- Develop and deliver training and education to clinical, CDI and coding professionals regarding CDI practices, coding and documentation requirements.
- Actively communicate with providers to clarify information and communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality.
- Develop and recommend policies and procedures; develop written procedures to clarify or describe standard practices; coordinate the publication and dissemination of procedures.
- Ensure admission reviews of patients' records are completed within 24-hours of notification of admission to evaluate and analyze documentation in order to assign the principal diagnosis, pertinent secondary diagnoses and procedures for accurate and optimal CMS-Diagnostic Related Group (CMS-DRG) assignment.
- Initiate and perform concurrent documentation reviews of selected inpatient and outpatient records to clarify conditions/diagnoses and procedures where inadequate or conflicting documentation exists, and conduct follow-up reviews as necessary.
- Develop and implement methods of improving the clarity, accuracy and completeness of clinical documentation; monitor and evaluate coding outcomes and provide periodic status to medical center departments and committees.
- Communicate with and serve as a resource for physicians, nurses, and other healthcare providers to facilitate complete and accurate documentation of the patient record; query physicians regarding missing, unclear or conflicting medical record documentation and obtain additional documentation; keep physician leaders informed of pertinent data, documentation trends and opportunities for learning and improvement related to documentation integrity.
- Collect data for performance improvement and report findings and outcomes; participate in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
- Participate in revenue cycle meetings, providing data relative to reimbursement concerns; educate physicians and healthcare providers regarding documentation matters related to coding, billing and reimbursements.
- Select, train, assign, discipline, and evaluate the work of an assigned staff; write and discuss work performance evaluations.
Minimum Requirements:OPTION IEducation: Graduation from an accredited college or university with a bachelor's degree in nursing.
Experience: Four years as a Registered Nurse in an acute care hospital.
License: Must possess and maintain a current valid license to practice as a Registered Nurse in the State of California.
Possession of valid Basic Life Support (BLS) Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) certificates issued by the American Heart Association for professional healthcare providers.
OPTION IIEducation: Graduation from an accredited college or university with a bachelor's degree in health information management or health information technology.
Experience: Five years of professional coding and abstracting medical records in an acute care hospital.
Certificate: Possession of valid certification as a Certified Coding Specialist (CCS), Registered Health Information Technician or Registered Health Information Administrator issued by the American Health Information Management Association.
OPTION IIIEducation: Completion of Doctor of Medicine degree.
Experience: Two years of performing clinical documentation improvement in a healthcare setting.
Certificate: Possession of valid certification as a Certified Coding Specialist (CCS), Registered Health Information Technician or Registered Health Information Administrator issued by the American Health Information Management Association. Certification in clinical documentation preferred.
ALL OPTIONSKnowledge of: The principles and practices of public and/or business administration; principles and practices of organizational analysis, fiscal management, budget preparation, control and contract monitoring, and personnel management; principles and practices of supervision; coding, abstracting and terminology systems such as: International Classification of Diseases, Clinically Modified (ICD-10) and Current Procedural Terminology (CPT- 4); comprehensive medical terminology covering a wide variety of medical specialties; clinical documentation standards; federal, state and local laws and regulations governing professional aspects of nursing; payor source documentation requirements and governmental regulations affecting reimbursement.
Ability to: Analyze administrative problems, reach practical and logical conclusions and put effective solutions into practice; develop cooperative working relationships; plan, organize, train, supervise, and evaluate the work of others; prepare clear and concise reports; analyze and interpret the technical elements of a medical chart; analyze, code and abstract complex technical data from medical records covering a wide variety of medical specialties utilizing an encoder and electronic abstracting system; prepare and maintain concise and complete records and reports; establish and maintain effective working relationships with physicians, patients and fellow employees; maintain effective communication skills.
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