Job Description
JOB SUMMARY
Collects and analyzes data to provide reports for hospital wide use and to make recommendations as appropriate. Participate in the planning, development and implementation, and ongoing success of the Clinical Documentation Management Program within the company. Educates members of the patient care team regarding documentation guidelines, including attending physicians, nursing, and other interdisciplinary team members. Responsible for reviewing medical records to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient, by improving the quality of the physicians’ clinical documentation and completeness of clinical documentation.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Include the following. Others may be assigned.
Monitoring and Building CDI team
Oversee and act as resource for Clinical Documentation Improvement departments across Conifer Health including monitoring daily activity and completion of performance and metric reports.
Test, interview, hire and retain CDI staff.
Lead meetings with team leads and CDI l staff
Improve medical CMI
Oversee market CDI programs
Enforces company, departmental policies, practices, procedures and work rules in accordance with approved policies and assists in the development and implementation of new policies.
Education/Development/Communication
Educates department and facility staff as needed
Communicates/Completes Clinical Documentation Improvement (CDI) activities and coding issues (lacking documentation, physician queries, etc.) for appropriate follow-up and resolution
Develop a collaborative CDI and Coding team
CDI leader for ICD 10 impact – ICD10 Core team and education leader of CDI staff
Analysis/Implementation
Performs analysis, identifies trends, validation of compliance as related to the clarity of documentation.
Analysis and interpretation of regional and facility-specific data and CDI audits
Record Review:
As needed, completes initial medical records reviews of patient records within 24-48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG assignment, risk of mortality and severity of illness; and (b) initiate a review worksheet.
Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final MS-DRG assignment upon patient discharge, as necessary.
Formulate physician queries regarding missing, unclear or conflicting health record documentation by requesting and obtaining additional documentation within the health record, as necessary.
Collaborates with case managers, nursing staff and other ancillary staff regarding interaction with physicians regarding documentation and to resolve physician queries prior to discharge.
Professional Development:
Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-+-CM. Attends mandatory coding seminars on annual basis (IPPS and OPPS, ICD-+-CM and CPT updates) for inpatient.
Quarterly review of AHA Coding Clinic. Attends Quarterly Coding Updates and all coding conference calls as well as any required CDI education.
Other duties as assigned
SUPERVISORY RESPONSIBILITIES
If direct report positions are listed below, the following responsibilities will be performed in accordance with guidelines, policies and procedures and applicable laws. Supervisory responsibilities include interviewing, hiring, and training employees; planning, assigning and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.
No. Direct Reports (incl. titles) CDI Lead and CDI Specialist
No. Indirect Reports (incl. titles) CDI Specialist
KNOWLEDGE, SKILLS, ABILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
CDI Subject Matter Expert
Knowledge of Medicare Part A and familiar with Medicare Part B
Knowledge of disease pathophysiology and drug utilization
Knowledge of MS-DRG classification and reimbursement structures
PC/Systems literate including the Internet and MS office skills
Ability to apply coding conventions, official guidelines, and Coding Clinic advice to health record documentation
Management of multiple priorities – effective time management skills
Leadership and organizational skills along with critical, deductive reasoning and problem solving skills
Effective written and verbal communication skills including report writing and presentation skills
Capacity to work independently in a virtual office setting or at facility setting if required to travel for assignment.
Understand and communicate documentation strategies
Recognize opportunities for documentation improvement
Formulate clinically, compliant credible queries
Ability to maintain an auditing and monitoring program as a means to measure query process
Report writing with management review
Skilled in performing quality assessment/analysis
Detail oriented and analytical skills
Possesses the ability to motivate and maintain effective working relationships with staff and all stakeholders.
Demonstrates strength in both performance management and leadership development
Manage change while minimizing interruption at an operational and service level
Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-1+ vaccination, influenza vaccination, and/or any future required vaccines and screenings.
EDUCATION / EXPERIENCE
Include minimum education, technical training, and/or experience required to perform the job.
Three (3) or more years’ experience in CDI
Preferred: Graduate from a Nursing program, BSN, or graduate of Health Information Management RHIT, RHIA preferred.
Preferred: One (1) year supervisory experience or more
CERTIFICATES, LICENSES, REGISTRATIONS
Preferred: Active state Registered Nurse license or Certified Coding Specialist credential
Preferred: CDIP or CCDS
Preferred: RN, RHIT, RHIA, and CCS
PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Ability to sit for extended periods of time
Must be able to efficiently use computer keyboard and mouse to perform CDI functions assignments
Good Visual acuity
WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
OTHER
The ideal candidate will have clinical documentation experience in an acute care facility
Must be able to travel occasionally
As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities, and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!
Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, *** (including pregnancy), national origin, age, disability, genetic information, ****** orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship
Collects and analyzes data to provide reports for hospital wide use and to make recommendations as appropriate. Participate in the planning, development and implementation, and ongoing success of the Clinical Documentation Management Program within the company. Educates members of the patient care team regarding documentation guidelines, including attending physicians, nursing, and other interdisciplinary team members. Responsible for reviewing medical records to facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient, by improving the quality of the physicians’ clinical documentation and completeness of clinical documentation.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Include the following. Others may be assigned.
Monitoring and Building CDI team
Oversee and act as resource for Clinical Documentation Improvement departments across Conifer Health including monitoring daily activity and completion of performance and metric reports.
Test, interview, hire and retain CDI staff.
Lead meetings with team leads and CDI l staff
Improve medical CMI
Oversee market CDI programs
Enforces company, departmental policies, practices, procedures and work rules in accordance with approved policies and assists in the development and implementation of new policies.
Education/Development/Communication
Educates department and facility staff as needed
Communicates/Completes Clinical Documentation Improvement (CDI) activities and coding issues (lacking documentation, physician queries, etc.) for appropriate follow-up and resolution
Develop a collaborative CDI and Coding team
CDI leader for ICD 10 impact – ICD10 Core team and education leader of CDI staff
Analysis/Implementation
Performs analysis, identifies trends, validation of compliance as related to the clarity of documentation.
Analysis and interpretation of regional and facility-specific data and CDI audits
Record Review:
As needed, completes initial medical records reviews of patient records within 24-48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG assignment, risk of mortality and severity of illness; and (b) initiate a review worksheet.
Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final MS-DRG assignment upon patient discharge, as necessary.
Formulate physician queries regarding missing, unclear or conflicting health record documentation by requesting and obtaining additional documentation within the health record, as necessary.
Collaborates with case managers, nursing staff and other ancillary staff regarding interaction with physicians regarding documentation and to resolve physician queries prior to discharge.
Professional Development:
Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-+-CM. Attends mandatory coding seminars on annual basis (IPPS and OPPS, ICD-+-CM and CPT updates) for inpatient.
Quarterly review of AHA Coding Clinic. Attends Quarterly Coding Updates and all coding conference calls as well as any required CDI education.
Other duties as assigned
SUPERVISORY RESPONSIBILITIES
If direct report positions are listed below, the following responsibilities will be performed in accordance with guidelines, policies and procedures and applicable laws. Supervisory responsibilities include interviewing, hiring, and training employees; planning, assigning and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.
No. Direct Reports (incl. titles) CDI Lead and CDI Specialist
No. Indirect Reports (incl. titles) CDI Specialist
KNOWLEDGE, SKILLS, ABILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
CDI Subject Matter Expert
Knowledge of Medicare Part A and familiar with Medicare Part B
Knowledge of disease pathophysiology and drug utilization
Knowledge of MS-DRG classification and reimbursement structures
PC/Systems literate including the Internet and MS office skills
Ability to apply coding conventions, official guidelines, and Coding Clinic advice to health record documentation
Management of multiple priorities – effective time management skills
Leadership and organizational skills along with critical, deductive reasoning and problem solving skills
Effective written and verbal communication skills including report writing and presentation skills
Capacity to work independently in a virtual office setting or at facility setting if required to travel for assignment.
Understand and communicate documentation strategies
Recognize opportunities for documentation improvement
Formulate clinically, compliant credible queries
Ability to maintain an auditing and monitoring program as a means to measure query process
Report writing with management review
Skilled in performing quality assessment/analysis
Detail oriented and analytical skills
Possesses the ability to motivate and maintain effective working relationships with staff and all stakeholders.
Demonstrates strength in both performance management and leadership development
Manage change while minimizing interruption at an operational and service level
Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-1+ vaccination, influenza vaccination, and/or any future required vaccines and screenings.
EDUCATION / EXPERIENCE
Include minimum education, technical training, and/or experience required to perform the job.
Three (3) or more years’ experience in CDI
Preferred: Graduate from a Nursing program, BSN, or graduate of Health Information Management RHIT, RHIA preferred.
Preferred: One (1) year supervisory experience or more
CERTIFICATES, LICENSES, REGISTRATIONS
Preferred: Active state Registered Nurse license or Certified Coding Specialist credential
Preferred: CDIP or CCDS
Preferred: RN, RHIT, RHIA, and CCS
PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Ability to sit for extended periods of time
Must be able to efficiently use computer keyboard and mouse to perform CDI functions assignments
Good Visual acuity
WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
OTHER
The ideal candidate will have clinical documentation experience in an acute care facility
Must be able to travel occasionally
As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities, and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!
Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, *** (including pregnancy), national origin, age, disability, genetic information, ****** orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship
💡 Quick Summary
Seeking a career-building opportunity? The CDI Supervisor - Houston, TX position is now open for candidates interested in the Nurse / Compounder Jobs sector. This role in Houston offers a professional environment and growth potential.
Requirement Snapshot: Candidates should possess basic communication skills, a proactive attitude, and the ability to work in a team. Experience in Nurse / Compounder Jobs is a plus.
