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Under the general supervision of the Director of Case Management, the Clinical Documentation Improvement Supervisor is accountable for systems of service delivery, staff oversite, performance management, recruitment, orientation, staffing and scheduling. Collaborates with the director in department planning, evaluation, training and development, performance improvement and budget management activities. Oversees, evaluates and directs day-to-day operations of the Clinical Documentation Specialists and assists with Departmental staffing as needed. Meets with HIM Leadership and coders on an ongoing basis to identify improvement opportunities and identify trends.
Ensures the appropriate physician documentation for any clinical conditions or procedures which support the appropriate severity of illness, expected risk of mortality and the complexity of care of the patient population. This individual exhibits a sufficient knowledge of clinical documentation requirements, DRG assignment, and clinical conditions and procedures for the pediatric patient population. This individual also educates members of the patient care team regarding documentation guidelines, including attending physicians, allied health practitioners, nursing staff, and case management.
• Provides direction and oversite of staff in assigned areas.
• Collaborates with Director in providing leadership and management of the Clinical Documentation Program operations including day-to-day activities, planning and performance management.
• Participates in the establishment and implementation of departmental goals.
• Interviews prospective candidates for departmental positions and makes recommendations about hiring to the director.
• Implements plans for the orientation and mentoring of new staff in the department.
• Provides direct supervision of staff in assigned areas of responsibility including training, development, and recognition and performance management.
• Completes initial and subsequent concurrent reviews of pediatric inpatient medical records in accordance with established timelines, in order to promote accurate code and DRG assignment and assessment of risk of mortality and severity of illness.
• Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation in the health record when needed.
• Collaborates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation issues and strives to resolve physician queries prior to patient discharge.
• Reviews and clarifies clinical issues in the health record with the coding professionals to support accurate DRG assignment, severity of illness, and/or risk of mortality.
• Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
• Supports and participates in the continuous assessment and improvement of the quality of services provided.
• Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
• Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership.
• Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective documentation reviews and aggregate data analysis.
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