Supervisor Clinical Documentation Improvement

The Clinical Documentation Improvement (CDI) Supervisor directly supervises a designated team of clinical documentation specialists, overseeing staffing and daily operations of the CDI activities to facilitate clinical documentation accuracy, and completeness of patient records within the health system. This role collaborates closely with CDI leads/leaders, coding, and healthcare providers to support clinical documentation improvement initiatives for coding accuracy, meeting regulatory standards and in support of optimal patient medical records. The supervisor works with CDI leaders and staff in support of compliant and effective CDI activity within identified areas for improvement, facilitating best practices in clinical documentation processes.

LEADERSHIP

• Participates in applicant interviews, final selection decisions, and CDI staff hiring activities as designated.

• Leads, facilitates, and coordinates onboarding, orientation, training, education, staff development, departmental activities, and in-service opportunities for Clinical Documentation Specialists staff.

• Assist with CDI staff meetings and CDI staff education activities.

• Conducts or facilitates team member audits and regular team member rounding. Establishes, monitors, and maintains productivity and quality benchmarks for CDI staff; initiates corrective action when necessary; keeps leadership informed; and may delegate portions of the CDS performance evaluation content preparation, rounding meetings, and/or audit feedback to appropriate CDI Coordinators.

• When indicated, and under the supervision and guidance of a CDI Manager (or CDI Director), participate in the planning and implementation of team member performance improvement plan or corrective action and counseling in fair and consistent manner, in accordance with organizational policies.

  CDI OPERATIONS

• Manages and coordinates CDI operations at the facility and regional level and demonstrates the ability to plan, initiate, and coordinate departmental operations.

• Maintain appropriate lines of communication, related to aspects of CDI operations.

• Manages daily concurrent review activity, including monitoring productivity, staffing, assignments, and delegation of responsibilities to appropriate CDI Coordinators as indicated.

• Works with senior management team, consultants, and executives on CDI projects and in meetings as designated.

  QUALITY AND COMPLIANCE

• Maintains appropriate controls to ensure compliance with Federal/State regulations and organizational policies to include HIPAA, Privacy, Safe Environment. Serves as the liaison with FMOL Health Compliance and system leadership.

• Promotes the quality and efficiency of his/her own performance by remaining current with the latest trends in field of expertise through participation in job relevant seminars and workshops, attendance at professional conferences, and affiliations with national and state professional organizations.

• Reviews and produces requested or routine audit information or reports and provides appropriate feedback to CDI leaders or staff in a timely manner. Maintains an organized work environment; promotes organization and cleanliness throughout area of supervision.

• Facilitates query compliance and resolution processes, including escalation, and monitors and evaluates the effectiveness of concurrent chart review and query outcomes at designated intervals.

  PHYSICIAN AN INTERDISCIPLINARY COLLABORATION

• Works closely with physicians and other healthcare providers as a CDI resource, supporting accurate and compliant clinical documentation. Serves as a resource for team members and physicians by linking coding guidelines and medical terminology to improve documentation quality and the accuracy of final code assignment.

• Work in collaborative fashion with coders, CDSs, CDI Coordinators, physician advisors, consultants, and management staff.

• Partners with CDI Physician Advisors and medical staff leadership to promote physician engagement, documentation improvement, query compliance, and provider education initiatives, as designed by CDI leadership.

REPORTING ANALYTICS AND PROGRAM IMPROVEMENT

• Works directly with CDI leadership on data trends and/or operational changes for improvement in compliance with the practice quality improvement initiatives.

• Works with CDI staff, vendors, and CDI leadership to monitor and evaluate CDI data and outcomes accurately and timely to hospital departments, committees, and other designated stakeholders, as designated by CDI leadership.

• Assists and facilitate audit process, including performing chart reviews and data analysis.

Experience: Supervisory or team lead experience and s

Six years of combined experience in:

• Clinical nursing and Clinical Documentation Integrity (CDI), or
• Acute care inpatient coding and Clinical Documentation Integrity (CDI)

Education:

• Graduate of an accredited school of nursing or
• Associate's degree in health information management with 2 years of experience or
• Bachelor's degree in Health Information Management

Certification/Licensure:

• Certified Coding Specialist (CCS) or
• Active Registered Nurse license