Clinical Documentation Integrity RN Supervisor CDI/Full-Time

POSITION SUMMARY: The Clinical Documentation Supervisor is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The CDI supervisor will provide support and expertise through comprehensive assessment and review of inpatient medical records. The CDI Supervisor will facilitate accurate DRG assignment and obtain appropriate documentation through extensive interaction with physicians, ancillary healthcare providers, and health information management coding staff to ensure that reimbursement (reflecting the proper quality of care and appropriate reimbursement) is received for the level of services rendered to the patients. Offers guidance and support to RN Clinical Documentation Specialists and assists the Director as needed. Coordinates meetings between CDI specialists and coders. Provides medical director/physician advisor appropriate data reports for MD outreach due to lack of query response. This is a fulltime FTE of 40 hours a week. FTE breakdown will consist of 60% concurrent assignment/chart review and 40% administrative time.

MINIMUM QUALIFICATIONS: Graduate from a Registered Nurse program; current New Mexico RN license required

EDUCATION:  graduate from a registered nurse program; BSN preferred

CERTIFICATION/LICENSES: Current New Mexico RN license

SKILLS:

• Basic computer skills in word processing and spreadsheet utilization
• Excellent written and verbal communication skills
• Proficient in computer use (desktop and/or laptop)
• Demonstrates basic knowledge regarding HIM coding standards
• Analytic skills necessary to accurately assess patient medical records
• Excellent interpersonal skills and ability to work on a team
• Ability to be flexible and adjust to workload/assignment changes and interruptions

EXPERIENCE:  Minimum of 5 years recent experience in healthcare required. Prior experience in clinical documentation improvement, utilization review/management, discharge planning, quality management, case management or coding preferred

NATURE OF SUPERVISION: 

-Responsible to: The Director of case management and The physician Advisor

ENVIRONMENT:

Bloodborne pathogen

General office environment and general hospital department/nursing units

PHYSICAL REQUIREMENTS: Ability to walk and stand 80% of work time