Location: Philadelphia, PA
Duration: 9+ Months
Experience in The Following:
- Case Management
- Clinical Documentation
- 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.
- Adheres to established departmental policies, procedures, and objectives.
- Enhances professional growth and development by accessing educational programs, job related literature, in-service meetings, and workshops/seminars.
- Enhances professional growth and development through participation in educational programs, current literature, in-service meetings and workshops.
- Maintains established department/hospital/system policies and procedures, directives, safety, environmental and infection control standards appropriate to this position.
- Demonstrates a courteous and professional manner through interactions with internal and external customers.
- Integrates scientific principles and research based knowledge in decision making.
- Exemplifies a professional image in appearance, manner and presentation.
- Engages in self-performance appraisal, identifying areas of strength as well as areas for professional development.
- Researches, selects and promotes adaptation of best practice findings to ensure quality patient care and optimal outcomes.
- Adapts behavior as needed to the specific patient population, including but not limited to: respect for privacy, method of introduction to the patient, adapting explanation of services or procedures to be performed, requesting permissions and communication style.
- Performs other related duties as assigned.
Additional Technical Requirements:
- Ability to work effectively with all departments and all levels of professionals.
- Ability to work independently or within a team structure.
- Must be very organized and able to work independently.
- Ability to establish priorities among multiple needs, meet deadlines and maintain standards of productivity.
- Computer skills and a working knowledge of Word, Excel and Access.
- Strong knowledge base in complete and accurate clinical documentation in the acute care setting and for all healthcare disciplines.
- Strong knowledge base and experience in interpreting and applying federal/government regulations to ensure coding and documentation compliance
- Strong knowledge base of the conventions, rules and guidelines for multiple classification and reimbursement systems (i.e. ICD -10, DRGs, APR-DRGs, etc).
- Ability to establish rapport with physicians and other healthcare practitioners.
- Demonstrated knowledge of medical terminology, anatomy and physiology, pharmacology, computers, and encoding software.
- Demonstrated interpersonal, critical thinking, and time management skills.
- Strong communication, teaching and presentation skills; must be detail oriented, and possess good problem solving skills
Registered Nursing License in Commonwealth of Pennsylvania or State of New Jersey, depending on assigned work location OR One or more of the following HIM credentials:
- Registered Health Information Administrator (RHIA)
- Registered Health Information Technician (RHIT)
- Certified Professional Coder (CCS) offered by the American Association of Professional Coders
- Certified Coding Specialist-Physician (CCS-P) offered by the American Health Information Management Association
- Certified Clinical Documentation Specialist (CCD)
- Certified Documentation Improvement Practitioner (CDIP)
Required Education and Experience:
- BSN from an ACEN and/or CCNE accredited school of nursing or college with at least 5 years acute care pediatric nursing experience (e.g., ED, ICU, case management, etc.) OR BS in HIM from an AHIMA accredited HIM program with at least 5 years of HIM inpatient coding experience (pediatric-focused coding preferred).
- Previous experience as a clinical documentation specialist