Job Summary: Reporting to the Director, Medical Records, the Clinical Documentation Specialist (CDS) Supervisor, is an active member of the Medical Record Department management team, responsible for overseeing the daily functions of the Clinical Documentation Improvement program. This includes concurrent review of inpatient medical records to identify documentation issues and opportunities for improving the quality of physician documentation. The CDS staff identify missing documentation of diagnoses and procedures, inappropriate terminology and opportunities for more complete documentation. The CDS staff facilitate clinical documentation improvement through extensive daily interaction with physicians, caregivers, care coordinators and coding staff performing informal and formal education. The CDS staff strive to achieve a complete medical record at patient discharge to insure accurate and compliant capture of patient acuity and severity levels that result in accurate reimbursement and accurate data to support quality indicators and other hospital metrics.
Minimum Qualifications Education: BSN or BS in biology or relevant healthcare clinical program ie. Medical Records. Experience: 3-5 years acute care or equivalent clinical setting; or 3 years inpatient coding experience Licensure and/or Certification: Current MA RN license and/or AHIMA Coding Certification required Skills: Able to work independently Excellent communication skills, both verbal and written Establish effective relationships with wide variety of health care providers Excellent team member; receives and shares information Good problem solver with strong critical thinking ability. Remains organized in spite of frequent interruptions. Computer skills to include learning software systems as needed Good time management skills to prioritize multiple tasks of interpreting medical record documentation, writing reports and correspondence, present information, work with mathematical concepts such as fractions, percentages, ratios and relate to practical situations. Responds to written or verbal assignments accurately and within established timeframes. Knowledge of DPH regulations, Medicare/CMS Rules and Regulations Understanding of Joint Commission standards and the CQI process. Ability to maintain confidential information. Supervision Received General Supervision