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.
Responsibilities:
- 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 I
Education: 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 II
Education: 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 III
Education: 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 OPTIONS
Knowledge 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.
Reasonable Accommodations
The County of Riverside is committed to providing reasonable accommodation to applicants as required by the Americans with Disabilities Act (ADA) and Fair Employment and Housing Act (FEHA). If you are a qualified individual and need a reasonable accommodation to take this exam, contact the recruiter before taking the exam.
Veterans’ Preference
The County has a Veterans Preference Policy. Upload a copy of your (or your spouse’s) Member-4 Form DD-214 (or NGB-22) indicating dates of service, and a copy of your spouse’s letter of disability (if applicable) with your application.
Pre-Employment
All employment offers are contingent upon successful completion of both a pre-employment physical exam, including a drug/alcohol test, and a criminal background investigation, which involves fingerprinting. (A felony or misdemeanor conviction may disqualify the applicant from County employment).
Probationary Period
As an Approved Local Merit System, all County of Riverside employees, except those serving "At Will," are subject to the probationary period provisions as specified in the applicable Memorandum of Understanding, County Resolution, or Salary Ordinance. Temporary and Per Diem employees serve at the pleasure of the agency/department head.
What’s Next?
Open to All Applicants
This recruitment is open to all applicants. Applicants who are current County of Riverside employees and/or current employees of The Riverside University Health System may be considered before other applicants depending on the volume of applications received.
Application Period
BASED ON THE NUMBER OF APPLICATIONS RECEIVED, THIS POSTING MAY CLOSE WITHOUT NOTICE. Applications received prior to the closing date will be considered based on the information submitted.
For questions regarding this recruitment contact the recruiter, Angela Levinson: alevinson@rivco.org / 951-955-5562
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