Documentation supervisor job description
Updated March 14, 2024
11 min read
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Example documentation supervisor requirements on a job description
Documentation supervisor requirements can be divided into technical requirements and required soft skills. The lists below show the most common requirements included in documentation supervisor job postings.
Sample documentation supervisor requirements
- Minimum of Bachelor's degree in related field
- At least 3 years of experience in a documentation role
- Expertise in document management systems
- Excellent written and verbal communication skills
Sample required documentation supervisor soft skills
- Strong leadership skills and ability to manage a team
- Detail-oriented and highly organized
- Ability to work under pressure and meet tight deadlines
- Strong problem-solving and analytical skills
- Excellent interpersonal and collaboration skills
Documentation supervisor job description example 1
Kaiser Permanente documentation supervisor job description
Supervises the Clinical Documentation Integrity (CDI) program, identifying areas of focus for improvement opportunity through report analysis interpretation of process and operational reports, financial and compliance reports, and quality rating reports. Assists with various associated operational matters including appropriate scheduling and coverage of reviews, query development and auditing, educating physicians, monitoring the program, and refining the process as needed to clarify documentation in records. Coordinates follow-up on unanswered queries during the patient stay, as needed to obtain prompt response to open queries. Works collaboratively with the CDI team to facilitate documentation with physician, case manager, utilization reviewer, nurse or other healthcare professionals, utilizing appropriate querying tools to capture needed documentation.
Essential Responsibilities:
+ Supervises individual(s) including but not limited to: hires, trains, assigns work, manages and evaluates performance, conducts professional development plans. Ensures that the productivity and actions of that group meet/support the overall operational goals of the department as established by department leadership.
+ Works region-wide to implement and monitor departmental policies and procedures that support organizational goals, business objectives and Clinical Documentation accuracy and data quality.
+ Performs periodic queries in a production context to provide feedback and expertise on areas of opportunity as it relates to the department workflow.
+ Represents the department at all required Clinical Documentation meetings with external stakeholders as needed.
+ Oversight of day to day operations of assigned CDISC team members to include, but not limited to timekeeping, performance reviews, CDI workflow enhancements based on quality audits, root cause analysis on performance variability to establish best practices, and Physician champion outreach.
+ Maintains limited daily assignment for clinical reviews.
+ Develops recommendations as required to documentation templates; scorecards, physician queries based on coding and documentation changes, regulatory modifications and quality review findings.
+ Responds to documentation inquiries from other Maui Health departments including but not limited to Quality and Core metrics, and Patient Safety.. Reviews and reports on monthly scorecards.
+ Facilitates compliance with regulatory documentation / coding requirements and improves the quality of health information data.
+ Provides clinical content expertise to HIM coders as required.
+ Establishes effective working relationships with HIM directors, providers, physician reviewers and HIM data quality managers.
+ Conducts data analysis and clinical research as required.
+ NOTE: Travel may be required.
Basic Qualifications:
Experience
+ Minimum three (3) years of work experience in clinical nursing, Healthcare Consulting, Operations or Project management, in a health care setting.
+ Minimum two (2) years of experience in health information management or clinical documentation.
+ Minimum one (1) year of management, supervisory or leadership* experience.
Education
+ Bachelors degree in nursing, business administration, health care, public health, finance, business health information management) OR four (4) years of experience in a directly related field.
+ High School Diploma or General Education Development (GED) required.
License, Certification, Registration
+ Registered Nurse License (Hawaii) required at hire
+ Documentation Improvement Practitioner Certificate
Additional Requirements:
+ *Leadership experience will be permissible for Kaiser Permanente internal applicants only and is defined by the following criteria: Demonstrated clinical nursing leadership as a Charge/Senior RN, participation on professional committees inclusive of UBTs, National Certification in Specialty, and/or demonstrated experiential exposure to Nursing Leadership.
+ Demonstrate ability to understand, utilize and apply the methods, principles, practices and techniques related to coding of health information data.
+ Working knowledge of MS-DRGS and HCCs including, but not limited to, International Classification of Diseases Clinical Modification (ICD-CM)
+ Demonstrate ability to interact with diverse groups at all levels of the organization and must have excellent communication & presentation skills (written and verbal).
+ Demonstrate ability to work in a team environment, build effective teams &motivated self-starter.
+ Demonstrate ability to respond to detailed clinical documentation questions from Hospital HIM coders, nurses or physicians; reviews analytical data and monitor clinical documentation scorecards and communicates training needs to external stakeholders as required.
+ Demonstrate experience with results-oriented approach.
+ Must excel in a collaborative and consensus building environment.
Preferred Qualifications:
+ Management and clinical experience.
+ Previous nursing management experience in an acute care setting and/or management consulting experience preferred.
+ Previous EPIC or electronic health record (EHR) experience preferred.
+ Masters degree preferred.
+ Successful completion of a professional American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC) sponsored/recognized coding course
+ Certified Professional Coder (CPC), Certified Professional Coder-Physician (CPC-P), or Certified Professional Coder-Hospital (CPC-H) by the American Academy of Professional Coders (AAPC)
COMPANY: KAISER
TITLE: Clinical Documentation Integrity Supervisor
LOCATION: Wailuku, Hawaii
REQNUMBER: 1082034
External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.
Essential Responsibilities:
+ Supervises individual(s) including but not limited to: hires, trains, assigns work, manages and evaluates performance, conducts professional development plans. Ensures that the productivity and actions of that group meet/support the overall operational goals of the department as established by department leadership.
+ Works region-wide to implement and monitor departmental policies and procedures that support organizational goals, business objectives and Clinical Documentation accuracy and data quality.
+ Performs periodic queries in a production context to provide feedback and expertise on areas of opportunity as it relates to the department workflow.
+ Represents the department at all required Clinical Documentation meetings with external stakeholders as needed.
+ Oversight of day to day operations of assigned CDISC team members to include, but not limited to timekeeping, performance reviews, CDI workflow enhancements based on quality audits, root cause analysis on performance variability to establish best practices, and Physician champion outreach.
+ Maintains limited daily assignment for clinical reviews.
+ Develops recommendations as required to documentation templates; scorecards, physician queries based on coding and documentation changes, regulatory modifications and quality review findings.
+ Responds to documentation inquiries from other Maui Health departments including but not limited to Quality and Core metrics, and Patient Safety.. Reviews and reports on monthly scorecards.
+ Facilitates compliance with regulatory documentation / coding requirements and improves the quality of health information data.
+ Provides clinical content expertise to HIM coders as required.
+ Establishes effective working relationships with HIM directors, providers, physician reviewers and HIM data quality managers.
+ Conducts data analysis and clinical research as required.
+ NOTE: Travel may be required.
Basic Qualifications:
Experience
+ Minimum three (3) years of work experience in clinical nursing, Healthcare Consulting, Operations or Project management, in a health care setting.
+ Minimum two (2) years of experience in health information management or clinical documentation.
+ Minimum one (1) year of management, supervisory or leadership* experience.
Education
+ Bachelors degree in nursing, business administration, health care, public health, finance, business health information management) OR four (4) years of experience in a directly related field.
+ High School Diploma or General Education Development (GED) required.
License, Certification, Registration
+ Registered Nurse License (Hawaii) required at hire
+ Documentation Improvement Practitioner Certificate
Additional Requirements:
+ *Leadership experience will be permissible for Kaiser Permanente internal applicants only and is defined by the following criteria: Demonstrated clinical nursing leadership as a Charge/Senior RN, participation on professional committees inclusive of UBTs, National Certification in Specialty, and/or demonstrated experiential exposure to Nursing Leadership.
+ Demonstrate ability to understand, utilize and apply the methods, principles, practices and techniques related to coding of health information data.
+ Working knowledge of MS-DRGS and HCCs including, but not limited to, International Classification of Diseases Clinical Modification (ICD-CM)
+ Demonstrate ability to interact with diverse groups at all levels of the organization and must have excellent communication & presentation skills (written and verbal).
+ Demonstrate ability to work in a team environment, build effective teams &motivated self-starter.
+ Demonstrate ability to respond to detailed clinical documentation questions from Hospital HIM coders, nurses or physicians; reviews analytical data and monitor clinical documentation scorecards and communicates training needs to external stakeholders as required.
+ Demonstrate experience with results-oriented approach.
+ Must excel in a collaborative and consensus building environment.
Preferred Qualifications:
+ Management and clinical experience.
+ Previous nursing management experience in an acute care setting and/or management consulting experience preferred.
+ Previous EPIC or electronic health record (EHR) experience preferred.
+ Masters degree preferred.
+ Successful completion of a professional American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC) sponsored/recognized coding course
+ Certified Professional Coder (CPC), Certified Professional Coder-Physician (CPC-P), or Certified Professional Coder-Hospital (CPC-H) by the American Academy of Professional Coders (AAPC)
COMPANY: KAISER
TITLE: Clinical Documentation Integrity Supervisor
LOCATION: Wailuku, Hawaii
REQNUMBER: 1082034
External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.
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Documentation supervisor job description example 2
Stanford Health Care documentation supervisor job description
If you're ready to be part of our legacy of hope and innovation, we encourage you to take the first step and explore our current job openings. Your best is waiting to be discovered.
Day - 08 Hour (United States of America)
**This is a Stanford Health Care job.**
**A Brief Overview**
Supervises the staff and operational activities within the Document Imaging section, supervises section productivity, turn-around-times and quality of work. Trains new employees on policies and procedures and provides ongoing training /education to existing staff and ancillary areas performing doc prep and/or scanning as needed. Interacts with scanning vendor as needed. Completes performance appraisals and provides timely and appropriate feedback to employees. Assesses quality of work performed, prepares statistics and reports reflecting operational activity of the area writes and maintains policies and procedures with timely revisions as required for changes/updates. Responsible for timecards, staffing and coverage, responsible for daily rounding, huddles, timely data submissions, etc. Participates in the creation and input of A3's, Stanford Operating Procedures (SOP's), section goals, etc.
**What you will do**
+ Encompass CICARE at all times with coworkers, colleagues, leadership, providers, vendors, patients and all other interactions including verbal, written and behavioral communications.
+ Works closely with other members of the HIMS team, IT, the scanning vendor, clinic staff, Patient Access, Patient Financial Services, Guest Services, Compliance, Risk, Legal, etc. to ensure chart accuracy throughout all hospital systems.
+ May also support testing, new versions, system upgrades, new applications, etc. to ensure accurate results with minimal impact to end users, key stakeholders and functional areas.
+ Develops and maintains a Quality Assurance Program, assessing results monthly with feedback to staff.
+ Manages email and telephone correspondence in a timely manner.
+ Meets section performance standards by efficiently setting goals and objectives, prioritizing work, effectively using available resources, reviews standards and makes recommendations for change as needed.
+ Provides leadership and supervisory expertise regarding HIMS operations. Supervises staff, functions and resource utilization within the section.
+ Reports statistics reflecting operational activity in the area as well as status updates for projects/initiatives, etc.
+ Responsible for developing and maintaining effective, current training plans for new and existing employees.
+ Supervises section productivity, turn-around-times and quality of work.
+ Writes, maintains and updates policies and procedures for the section.
+ Writes performance appraisals with input from the HIMS Manager and/or Director, providing timely and appropriate feedback with appraisal completion within the defined time limits.
+ Conducts rounds and section huddles, participates in organizational huddles as required both day and evening.
+ Responsible for managing timecards, timely PTO request review, running reports for Time and Attendance, provides feedback to employees when required by Time & Attendance Policy.
+ Responsible for ensuring adequate staffing and holiday coverage.
+ Responsible for timely benchmark submissions for daily, monthly, and quarterly data and as needed.
+ Responsible for A3 creation and input for sections and SOP's.
+ Coordinates offsite storage for scanned records including retention and destruction efforts per policy.
+ Works with vendors for systems, record storage, couriers, etc. as needed for tasks related to documents in this section.
+ Devises goals, work plans, initiatives involving the staff with an Employee Engagement focus.
+ Conducts focused reviews for new and priority medical record forms to ensure accurate and complete patient information is contained in the EHR as it relates to scanned documents.
+ Generates productivity reports to monitor productivity, turnaround times, and quality of work and geographically displays data. Provides conclusions and recommendations.
+ Performs Quality Assurance audits of all DI staff, creating employee specific reports for tracking, trending and education opportunities. Reviewed the scanned documents to ensure the correct indexing (MRN, Account (CSN), and Document Type), file quality (no page omissions, duplicates or blanks) and image quality, ensuring a 985 accuracy rate.
+ Trouble shoots and corrects issues relating to misfiled scans, incomplete documentation, image quality, etc.
+ Utilizes various methods to verify provider, patient or system information to determine the appropriate resolution and required actions for correction.
+ Provides recommendations for improvement, based upon ongoing process reviews/findings and analysis.
+ Participates in JC mock surveys.
+ Educates physicians/clinic staff in facilitating accurate and complete clinical documentation with barcoding, labeling, indexing, etc.
+ Assists in running reports as needed/requested.
**Education Qualifications**
+ Associate degree in a work-related discipline/field from an accredited college or university.
**Experience Qualifications**
+ Two (2) years progressively responsible and directly related work experience and/or a combination of experience with RHIT/RHIA.
+ Three (3) years progressively responsibility and directly related work experience without credential.
**Required Knowledge, Skills and Abilities**
+ Ability to analyze relevant data as needed to support strategic decisions for the organization.
+ Ability to plan, organize, develop tactical plans and set priorities.
+ Ability to solve technical and non-technical problems.
+ Ability to supervise, coach, mentor, train and evaluate work results.
+ Ability to work effectively with individuals at all levels of the organization.
+ Knowledge of local, state and federal regulatory requirements related to functional areas of responsibility.
+ Knowledge of medical record review processes, data analysis and data display.
+ Ability to apply judgment and make informed decisions.
+ Ability to communicate complex concepts in simple form to cross-functional departments or teams.
+ Ability to conduct analysis and formulate conclusions.
+ Ability to plan, organize, and prioritize work independently and meet deadlines.
+ Ability to speak and write effectively at a level appropriate for the job.
+ Knowledge of new technologies (in specific fields) and maintain and stay abreast of updates and changes.
+ Knowledge of computer systems and software used in functional area.
+ Ability to manage, organize, prioritize, multi-task and adapt to changing priorities.
+ Ability to work effectively both as a team player and leader.
+ Ability to establish and maintain effective working relationships.
+ Ability to judgment and make informed decisions.
**These principles apply to ALL employees:**
**SHC Commitment to Providing an Exceptional Patient & Family Experience**
_Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford's patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery._
_You will do this by executing against our three experience pillars, from the patient and family's perspective:_
+ Know Me: Anticipate my needs and status to deliver effective care
+ Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health
+ Coordinate for Me: Own the complexity of my care through coordination
\#LI-RL1
**Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in** **all of** **its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.**
Day - 08 Hour (United States of America)
**This is a Stanford Health Care job.**
**A Brief Overview**
Supervises the staff and operational activities within the Document Imaging section, supervises section productivity, turn-around-times and quality of work. Trains new employees on policies and procedures and provides ongoing training /education to existing staff and ancillary areas performing doc prep and/or scanning as needed. Interacts with scanning vendor as needed. Completes performance appraisals and provides timely and appropriate feedback to employees. Assesses quality of work performed, prepares statistics and reports reflecting operational activity of the area writes and maintains policies and procedures with timely revisions as required for changes/updates. Responsible for timecards, staffing and coverage, responsible for daily rounding, huddles, timely data submissions, etc. Participates in the creation and input of A3's, Stanford Operating Procedures (SOP's), section goals, etc.
**What you will do**
+ Encompass CICARE at all times with coworkers, colleagues, leadership, providers, vendors, patients and all other interactions including verbal, written and behavioral communications.
+ Works closely with other members of the HIMS team, IT, the scanning vendor, clinic staff, Patient Access, Patient Financial Services, Guest Services, Compliance, Risk, Legal, etc. to ensure chart accuracy throughout all hospital systems.
+ May also support testing, new versions, system upgrades, new applications, etc. to ensure accurate results with minimal impact to end users, key stakeholders and functional areas.
+ Develops and maintains a Quality Assurance Program, assessing results monthly with feedback to staff.
+ Manages email and telephone correspondence in a timely manner.
+ Meets section performance standards by efficiently setting goals and objectives, prioritizing work, effectively using available resources, reviews standards and makes recommendations for change as needed.
+ Provides leadership and supervisory expertise regarding HIMS operations. Supervises staff, functions and resource utilization within the section.
+ Reports statistics reflecting operational activity in the area as well as status updates for projects/initiatives, etc.
+ Responsible for developing and maintaining effective, current training plans for new and existing employees.
+ Supervises section productivity, turn-around-times and quality of work.
+ Writes, maintains and updates policies and procedures for the section.
+ Writes performance appraisals with input from the HIMS Manager and/or Director, providing timely and appropriate feedback with appraisal completion within the defined time limits.
+ Conducts rounds and section huddles, participates in organizational huddles as required both day and evening.
+ Responsible for managing timecards, timely PTO request review, running reports for Time and Attendance, provides feedback to employees when required by Time & Attendance Policy.
+ Responsible for ensuring adequate staffing and holiday coverage.
+ Responsible for timely benchmark submissions for daily, monthly, and quarterly data and as needed.
+ Responsible for A3 creation and input for sections and SOP's.
+ Coordinates offsite storage for scanned records including retention and destruction efforts per policy.
+ Works with vendors for systems, record storage, couriers, etc. as needed for tasks related to documents in this section.
+ Devises goals, work plans, initiatives involving the staff with an Employee Engagement focus.
+ Conducts focused reviews for new and priority medical record forms to ensure accurate and complete patient information is contained in the EHR as it relates to scanned documents.
+ Generates productivity reports to monitor productivity, turnaround times, and quality of work and geographically displays data. Provides conclusions and recommendations.
+ Performs Quality Assurance audits of all DI staff, creating employee specific reports for tracking, trending and education opportunities. Reviewed the scanned documents to ensure the correct indexing (MRN, Account (CSN), and Document Type), file quality (no page omissions, duplicates or blanks) and image quality, ensuring a 985 accuracy rate.
+ Trouble shoots and corrects issues relating to misfiled scans, incomplete documentation, image quality, etc.
+ Utilizes various methods to verify provider, patient or system information to determine the appropriate resolution and required actions for correction.
+ Provides recommendations for improvement, based upon ongoing process reviews/findings and analysis.
+ Participates in JC mock surveys.
+ Educates physicians/clinic staff in facilitating accurate and complete clinical documentation with barcoding, labeling, indexing, etc.
+ Assists in running reports as needed/requested.
**Education Qualifications**
+ Associate degree in a work-related discipline/field from an accredited college or university.
**Experience Qualifications**
+ Two (2) years progressively responsible and directly related work experience and/or a combination of experience with RHIT/RHIA.
+ Three (3) years progressively responsibility and directly related work experience without credential.
**Required Knowledge, Skills and Abilities**
+ Ability to analyze relevant data as needed to support strategic decisions for the organization.
+ Ability to plan, organize, develop tactical plans and set priorities.
+ Ability to solve technical and non-technical problems.
+ Ability to supervise, coach, mentor, train and evaluate work results.
+ Ability to work effectively with individuals at all levels of the organization.
+ Knowledge of local, state and federal regulatory requirements related to functional areas of responsibility.
+ Knowledge of medical record review processes, data analysis and data display.
+ Ability to apply judgment and make informed decisions.
+ Ability to communicate complex concepts in simple form to cross-functional departments or teams.
+ Ability to conduct analysis and formulate conclusions.
+ Ability to plan, organize, and prioritize work independently and meet deadlines.
+ Ability to speak and write effectively at a level appropriate for the job.
+ Knowledge of new technologies (in specific fields) and maintain and stay abreast of updates and changes.
+ Knowledge of computer systems and software used in functional area.
+ Ability to manage, organize, prioritize, multi-task and adapt to changing priorities.
+ Ability to work effectively both as a team player and leader.
+ Ability to establish and maintain effective working relationships.
+ Ability to judgment and make informed decisions.
**These principles apply to ALL employees:**
**SHC Commitment to Providing an Exceptional Patient & Family Experience**
_Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford's patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery._
_You will do this by executing against our three experience pillars, from the patient and family's perspective:_
+ Know Me: Anticipate my needs and status to deliver effective care
+ Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health
+ Coordinate for Me: Own the complexity of my care through coordination
\#LI-RL1
**Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in** **all of** **its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.**
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Updated March 14, 2024
Updated March 14, 2024