Clinical Documentation Improvement Supervisor - RUHS - Medical Records - County of Riverside
Riverside, CA 92501
About the Job
Riverside University Health System-Medical Center is seeking a Clinical Documentation Improvement Supervisor for the Medical Records Department.
The most competitive candidates will have significant CDI experience and be familiar with EPIC and 3M Clinical Documentation Integrity Services. At least one certification as a Certified Coding Specialist (CCS), Registered Health Information Technician OR Registered Health Information Administrator issued by the American Health Information Management Association is strongly preferred.
Under direction, the incumbent supervises, plans, directs, and coordinates the operations of the Clinical Document Improvement (CDI) department; assures compliance to conduct complex and difficult research and analytical studies involving the operations and programs of the department served; makes recommendations for the development, implementation and improvement of departmental operations, services, and programs; performs other related duties as required.
The Clinical Document Improvement Supervisor is the supervisory level classification in the Clinical Document Improvement series, performing the full range of supervisory duties. Incumbents will coordinate and organize the CDI for both inpatient and outpatient services, facilitate physician documentation, denials, and coding, and collaborate with physicians, directors, providers, and other healthcare team members to make improvements that result in accurate, comprehensive documentation that reflects completely, the clinical treatment, decision, and diagnoses for the patient.
Incumbents may participate in the employee selection process, training, coaching and mentoring of employees.
Meet the Team!
Riverside University Health System-Medical Center consistently receives national recognition for its progressive and innovative care, as well as being known as one of the top employers in the region. The 439-bed Medical Center is a designated Stroke Center, Level II Trauma Center, and the only Pediatric ICU in the region. Can you see yourself here? For more information on RUHS-Medical Center, please visit www.ruhealth.org
For questions regarding this recruitment contact the recruiter,Angela Levinson:
alevinson@rivco.org / 951-955-5562
EXAMPLES OF ESSENTIAL DUTIES
• Plan, assign and direct the work of a unit of Clinical Documentation Improvement Specialists.
• Develop and deliver training and education to clinical, CDI and coding professionals regarding CDI practices, coding and documentation requirements.
• Actively communicate with providers to clarify information and communicate documentation requirements for appropriate diagnoses based on severity of illness and risk of mortality.
• Develop and recommend policies and procedures; develop written procedures to clarify or describe standard practices; coordinate the publication and dissemination of procedures.
• Ensure admission reviews of patients' records are completed within 24-hours of notification of admission to evaluate and analyze documentation in order to assign the principal diagnosis, pertinent secondary diagnoses and procedures for accurate and optimal CMS-Diagnostic Related Group (CMS-DRG) assignment.
• Initiate and perform concurrent documentation reviews of selected inpatient and outpatient records to clarify conditions/diagnoses and procedures where inadequate or conflicting documentation exists, and conduct follow-up reviews as necessary.
• Develop and implement methods of improving the clarity, accuracy and completeness of clinical documentation; monitor and evaluate coding outcomes and provide periodic status to medical center departments and committees.
• Communicate with and serve as a resource for physicians, nurses, and other healthcare providers to facilitate complete and accurate documentation of the patient record; query physicians regarding missing, unclear or conflicting medical record documentation and obtain additional documentation; keep physician leaders informed of pertinent data, documentation trends and opportunities for learning and improvement related to documentation integrity.
• Collect data for performance improvement and report findings and outcomes; participate in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
• Participate in revenue cycle meetings, providing data relative to reimbursement concerns; educate physicians and healthcare providers regarding documentation matters related to coding, billing and reimbursements.
• Select, train, assign, discipline, and evaluate the work of an assigned staff; write and discuss work performance evaluations.
MINIMUM QUALIFICATIONS
OPTION I
Education: Graduation from an accredited college or university with a bachelor's degree in nursing.
Experience: Four years as a Registered Nurse in an acute care hospital.
License: Must possess and maintain a current valid license to practice as a Registered Nurse in the State of California.
Possession of valid Basic Life Support (BLS) Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) certificates issued by the American Heart Association for professional healthcare providers.
OPTION II
Education: Graduation from an accredited college or university with a bachelor's degree in health information management or health information technology.
Experience: Five years of professional coding and abstracting medical records in an acute care hospital.
Certificate: Possession of valid certification as a Certified Coding Specialist (CCS), Registered Health Information Technician or Registered Health Information Administrator issued by the American Health Information Management Association.
OPTION III
Education: Completion of Doctor of Medicine degree.
Experience: Two years of performing clinical documentation improvement in a healthcare setting.
Certificate: Possession of valid certification as a Certified Coding Specialist (CCS), Registered Health Information Technician or Registered Health Information Administrator issued by the American Health Information Management Association. Certification in clinical documentation preferred.
ALL OPTIONS
Knowledge of: The principles and practices of public and/or business administration; principles and practices of organizational analysis, fiscal management, budget preparation, control and contract monitoring, and personnel management; principles and practices of supervision; coding, abstracting and terminology systems such as: International Classification of Diseases, Clinically Modified (ICD-10) and Current Procedural Terminology (CPT- 4); comprehensive medical terminology covering a wide variety of medical specialties; clinical documentation standards; federal, state and local laws and regulations governing professional aspects of nursing; payor source documentation requirements and governmental regulations affecting reimbursement.
Ability to: Analyze administrative problems, reach practical and logical conclusions and put effective solutions into practice; develop cooperative working relationships; plan, organize, train, supervise, and evaluate the work of others; prepare clear and concise reports; analyze and interpret the technical elements of a medical chart; analyze, code and abstract complex technical data from medical records covering a wide variety of medical specialties utilizing an encoder and electronic abstracting system; prepare and maintain concise and complete records and reports; establish and maintain effective working relationships with physicians, patients and fellow employees; maintain effective communication skills.
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APPLICATION INFORMATION
Veteran's Preference
The County has a Veterans Preference Policy applicable to new hires. To qualify, upload a copy of your (or your spouse's) Member-4 Form DD-214 indicating dates of service, and a copy of your spouse's letter of disability (if applicable) with your application. For privacy reasons, it is recommended that you remove your social security information from the document(s). A Human Resources Representative will review the materials and determine if you qualify for veterans' preference.The Veterans Preference Policy, C-3 is available here: https://rivcocob.org/board-policies
Reasonable Accommodations
The County of Riverside is committed to providing reasonable accommodation to applicants as required by the Americans with Disabilities Act (ADA) and Fair Employment and Housing Act (FEHA). Qualified individuals with disabilities who need a reasonable accommodation during the application or selection process should contact the recruiter for the position noted above. For additional information and/or to obtain the appropriate form for requesting a reasonable accommodation, please visit the Disability Access Office web page located at: https://rc-hr.com/disability
Proof of Education
If using education to qualify or when requested by the recruiter, upload a copy of any license(s), official/unofficial transcript(s), degrees, and/or related employment documents to your NeoGov account at the time of application and before the closing date. Official or unofficial transcripts will be accepted.
If your education was completed outside of the United States, you will need to provide a copy of your Foreign Education Equivalency evaluation from a member of the National Association of Credential Evaluation Services ( NACES ) or Association of International Credential Evaluators, Inc. ( AICE ).
Equal Opportunity Employer
The County of Riverside is an Equal Opportunity Employer. It is the policy of the County of Riverside to provide equal employment opportunities for all qualified persons. All applicants will be considered without regard to race, color, religion, sex, national origin, age, disability, sexual orientation, gender, gender identity, gender expression, marital status, ancestry, medical condition (cancer and genetic characteristics), genetic information, or denial of medical and family care leave, or any other non-job-related factors.
Pre-Employment
All employment offers are contingent upon successful completion of pre-employment requirements including a criminal background investigation, which involves fingerprinting. (A felony or misdemeanor conviction may disqualify the applicant from County employment). A pre-employment physical examination and background check may be required.
Probationary Period
As an Approved Local Merit System, all County of Riverside employees, except those serving "At Will," are subject to the probationary period provisions as specified in the applicable Memorandum of Understanding, County Resolution, or Salary Ordinance. Temporary and Per Diem employees serve at the pleasure of the agency/department head.
General Information
Current County of Riverside and/or current employees of the hiring department may receive priority consideration. Qualified candidates may be considered for future County vacancies.
Job postings may close without notice based on application volume. Submit your complete application by the recruitment close date; no late applications are accepted. Ensure all relevant experience/education is reflected on your application/resume, as a failure to demonstrate position requirements may disqualify applicants. A description of job duties directly copied from the job classification or job posting will not be considered.
Please read and follow any special application instructions on this posting. Click the 'Apply' link located on this page to submit your application. For additional instructions on the application process, examinations, Veteran's preference, pre-employment accommodation or other employment questions, please refer to our web site, www.rc-hr.com .
If you are experiencing technical problems, you may contact the governmentjobs.com applicant support desk Monday through Friday, 6 am to 5 pm Pacific Time at support@governmentjobs.com or toll-free 1-855-524-5627.
MEDICAL/DENTAL/VISION INSURANCE: A choice of different medical, dental and visions plan are available to elect. The County provides a Flexible Benefit Credit contribution as governed by the applicable SEIU Memorandum of Understanding to contribute towards the cost of these plans.
Note: Employees on assignment through the Temporary Assignment Program (TAP) receive different benefits. See the list here .
MISCELLANEOUS RETIREMENT: County of Riverside has three retirement Tiers through the California Public Employees' Retirement System (CalPERS).
- Tier I (Classic Member - Formula 3% @ 60): Applicable to current and former County of Riverside local miscellaneous employees hired prior to 08/24/2012 and did not withdraw CalPERS contributions. The employee contribution is eight (8%) percent.
- Tier II (Classic Member - Formula 2% @ 60): Applicable to local miscellaneous employees 1) hired after 08/23/2012 through 12/31/2012; 2) Previously employed with another CalPERS contracting public agency or a reciprocal retirement system, with a break in service of less than six months between the separation date with the previous employer and the appointment date with the County of Riverside. The employee contribution is seven (7%) percent.
- Tier III (PEPRA New Member - Formula 2% @ 62): Applicable to CalPERS local miscellaneous new members hired on or after the implementation of the Public Employees' Pension Reform Act of 2013 (PEPRA) which took effect January 1, 2013. Effective July 1, 2023 employee contributions are 7.25% and will increase to 7.75% effective July 1, 2024.
A new member is defined as any of the following:
CalPERS refers to all members that do not fit within the definition of a new member as "classic members".
Contribution rates are subject to change based on the County of Riverside annual actuarial valuation.
Note:
This summary is for general information purposes only. Additional questions regarding retirement formulas can be sent to retirement@rivco.org or by calling the Benefits Information Line at (951) 955-4981,
Option 2.
If you have prior service credit with another CalPERS agency or within agencies, please contact CalPERS at (888) 225-7377 to determine which retirement tier would be applicable to you. CalPERS is governed by the Public Employees' Retirement Law. The Retirement Law is complex and subject to change. If there's any conflict between this summary and the law, the law will prevail over this summary.
DEFERRED COMPENSATION: Voluntary employee contribution with a choice between two 457 deferred compensation plan options.
VACATION ACCRUAL (Bi-Weekly Accrual):
0< 3 year = 80 Hours (10 Days)
4< 9 years = 120 Hours (15 Days)
10 or more years = 160 Hours (20 Days)
Maximum Vacation leave accumulation is 480 hours.
SICK LEAVE: Four (4) hours Sick Leave accrual per pay period with unlimited accrual.
HOLIDAYS: Normally 12 paid holidays per year.
BEREAVEMENT LEAVE: Allowed 5 days (3 days are County paid; 2 additional days can be taken from accrued Sick Leave balance).
BASIC LIFE INSURANCE: Equal to one times annual base salary not to exceed $50,000 of term life coverage. Premiums are paid by the County. Additional Supplemental Life plan is available for employee purchase.
DISABILITY - LONG-TERM DISABILITY (LTD): Benefit pays 66.67% of earnings to a maximum of $10,000 per month; 30-day waiting period; pays to age 65. Benefit can be coordinated with other available leave balances to provide up to 100% of pay.
POST RETIREMENT MEDICAL CONTRIBUTION: A monthly contribution is made by the County towards retiree health insurance offered through the County as governed by the applicable SEIU Memorandum of Understanding.
OTHER: There may be other benefit provisions as specified in the applicable Memorandum of Understanding. Please contact the recruiter listed on the job posting directly for more information.