To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
The Clinical Documentation Specialist (CDS) Supervisor is responsible for supervising the group of Clinical Documentation Specialists across the Yale-New Haven Health System and the daily operations of this department. The Clinical Documentation Specialists perform the vital function of concurrent clinical chart review to assure accuracy of the medical record, quality and completeness. The CDS Supervisor will oversee the staffing and scheduling, performance reviews, employee performance management, support a streamlined chart review and query process, provide guidance on challenging clinical scenarios, and support staff with their interactions with providers. The supervisor will also review monthly performance records to ensure the department is reviewing all records in a timely and appropriate fashion. The supervisor will assure compliance with all hospital and regulatory guidelines.
- 1. Supervises daily operations and activities of the CDS group. This includes unit and case assignment across the health system.
- 2. In collaboration with the Manager, determines workflow priority and lead the CDS staff in meeting productivity standards and quality performance.
- 3. Responsible for the day to day supervision of operations in clinical documentation. Updates assignments and workflow changes to ensure resources are deployed in the most effective manner.
- 4. Holds staff meetings to keep CDS staff up to date on hospital initiatives and department changes.
- 5. Provides coverage in the absence of the Manager.
- 6. Supervises staff performance and in collaboration with the Manager, implements disciplinary action as needed.
- 7. In collaboration with the Manager, will provide educational plans for all levels of CDS at both a group and individual level. Provides continuous feedback throughout the year to staff on directed education and specific goals.
- 8. Participates in the interviewing and hiring of new staff and oversees new hire orientation.
- 9. Oversight for CDS audits to ensure compliant and effective queries.
- 10. Monthly maintenance and reporting of CDS dashboard to track impact of CDS group.
- 11. Standing presence on system CDMP Committee.
- 12. Supervises and supports CDS Leads with Provider education. Helps guide and deploy appropriate staff for clinician education.
- 13. Assists with IT strategy and implementation with Epic team and external software vendors.
- 14. Fosters strong relationships with Coding to create joint standards for chart review and querying by diagnosis. Continual review and audit to ensure adherence to joint standards.
- 15. Collaborates with coding in identified areas where clinical documentation and coding can improve workflow. Develops and maintains ongoing written procedures regarding workflow.
- 16. Focuses on improving relationships between Clinical Documentation and provider/provider groups. This entails ensuring new and effective educational efforts to a variety of clinical departments.
- 17. Ongoing communication and collaboration with Physician Advisor team.
- 18. In collaboration with the Manager, develops policies/guidelines to assure a smooth and compliant CDI program.
- 19. Performs other related duties and projects within the department as assigned by the Manager.
- 20. In collaboration with other members of the CDI management team and leadership team, synthesizes, interprets and presents data to senior leadership and financial, clinical and quality partners throughout the health system.
Minimum of a baccalaureate degree and/or currently pursuing a baccalaureate degree with an expected completion within one year of a job offer. RN required. Certified Clinical Documentation Specialist (CCDS)
through ACDIS and Certified Coding Specialist (CCS) through AHIMA required.
Minimum of five (5) years of relevant acute care clinical experience is required as a Registered Nurse. Previous supervisor or leadership experience is strongly preferred. Minimum of three (3) years of experience as a Clinical Documentation Specialist is preferred.
CT RN license required. Certified Clinical Documentation Specialist (CCDS) and Certified Coding Specialist (CCS) required
The applicant must have a strong fundamental knowledge of clinical medicine in order to maintain credibility with CDS staff, providers and Physician Advisors. The CDS Supervisor must possess strong interpersonal and communication skills to supervise and motivate the CDS staff and CDS Leads. Must demonstrate strong leadership skills, ability to counsel staff, strong organizational skills, ability to inspire and build confidence in others, and an ability to set and communicate priorities and knowledge of regulatory requirements around Clinical Documentation are of the highest importance for this role. Additionally, comfort with the electronic medical record and the ability to deal with complex clinical data in a computerized form is essential. The CDS Supervisor must ensure that documentation improvement is done with a sole regard to improving the accuracy of the patient record in that it best reflects the quality of care being delivered at the bedside.