Documentation Supervisor Job Description Sample
Supervisor Clinical Documentation Improvement
BON SECOURS RICHMOND HEALTH SYSTEM
Oversees site-based Clinical Documentation Improvement (CDI) program; monitors and maintains the timeliness of workflow, productivity, and quality of the site CDI program; develops and monitors implementation of site departmental goals/objectives and supports the performance improvement process in conjunction with the Clinical Documentation Manager. Ensures CDI operations support hospital policy, medical staff by-laws and regulatory and legal requirements, while maintaining a high degree of emphasis on physician satisfaction. Assists in the development and maintains departmental policies and procedures accordingly for the CDI program.
At least five years of nursing experience in either Med/Surg, Intensive Care, or Emergency Department required
At least two years of experience as a Clinical Documentation Specialist, preferably in the Bon Secours system; selfmotivated, strong organizational skills, excellent speaking and presentation skills.
Supervisor or management experience strongly preferred
Current RN license required (in the State you are seeking employment)
CCDS (Certified Clinical Documentation Specialist) certification or willingness to obtain certification within one year of role acceptance required
2 year/Associates Degree in Nursing required at minimum with a 4 year/Bachelor's Degree in Nursing preferred; Combination of post-secondary education and experience will be considered in lieu of degree
Willingness to update technical expertise and to develop management/leadership skills through continuing education throughout tenure in position; willingness to travel within the market
Legal Documentation Specialist
WHAT YOU CAN EXPECT
Do you share a passion for industry leading excellence, service, and a fun work environment? We are looking for a Legal Documentation Specialist to join the Trilogy family!
Maintains medical records in accordance with federal and state guidelines as well as established policies and procedures to assure that a complete medical records program is maintained. Ensures quality, accuracy, accessibility and security in both paper and electronic systems. Directs, analyzes, researches and comprehends critical data points to determine missing components of the comprehensive medical record. Provides guidance, support, communication and coordination of documents with multiple legal, operations, and clinical programs. Reviews all quality data to ensure accuracy and assist with quality improvement plans.
Duties and Responsibilities
Responsible for gathering, printing, and collecting all responsive pieces of a requested medical record for production to resident, authorized representative, or attorney. This includes direct contact with campuses, including potential travel to campuses as needed, to ensure all records are obtained.
Work with Clinical Risk Manager to assist with identifying potential compensable events.
Work with Campuses to ensure incident workflow and soft files are completed as necessary when notified of certain events.
Utilizes various classification systems to code and categorize patient information for risk and legal reviews.
Assists in the development of procedures to ensure records are properly stored and copied for production requests.
Work with Compliance to ensure proper authority for the production of requested records.
Protects the security of medical records to ensure confidentiality is maintained.
Reviews records for completeness, accuracy and compliance with regulations.
Assist with developing and providing training on record documentation and retention.
Travel could be as much as 50%, including overnight stay as necessary.
WHAT WE'RE LOOKING FOR
- Bachelor's Degree
Two (2) to Five (5) years' experience in healthcare, senior living industry or long- term care environment preferred.
Sufficient skills with Navision, Jet Reports and Matrixcare software products or equivalent preferred.
Exemplary computer skills that include knowledge of the Microsoft Office Suite of products.
LOCATIONTrilogy Health Services Louisville KentuckyTEXT ONE OF OUR RECRUITERSMeredith (419) 951-0423LIFE AT TRILOGY
Headquartered in Louisville, KY, Trilogy Health Services was founded in December 1997 and is dedicated to being the Best Healthcare Company in the Midwest by providing exceptional, comprehensive care to seniors in our living communities. Trilogy has over 100 locations and continues to grow across IN, OH, MI and KY. Join our growing company and experience the Trilogy Difference. We care for you while you care for others. #C4U
The Trilogy Advantage
Competitive Salaries & Weekly Pay
Innovative Training Programs
FREE Health Insurance Option
- up to $1,500 in company contributions
Tuition Reimbursement, Scholarships and Student Loan Repayment
And much more!
Equal Opportunity Employer
Trilogy Hires Heroes Just Like YOU!
Documentation & Modification Specialist - Loan Doc & Funding Control
The primary purpose of this position is to prepare loan documents and/or modification documents for Commercial and Business Banking Loans per Credit Policy guidelines. The position requires a good understanding of loan documents in order to document the appropriate changes/modifications to the original loan documents.
The position works closely with lending staff and the Bank's Corporate Counsel on modifications that require specific changes that are not supported by the Bank's loan documentation software. Maintain a comprehensive knowledge of applicable state and federal regulations applicable to your conduct and the work you will be performing.
Consideration for location will be in Wheeling, WV; Weirton, WV; Charleston, WV; Huntington, WV; Jackson, OH; Mason, OH; Ellwood City, PA; New Albany, IN; Frankfort, KY; Newport, KY or Versailles, KY.
CUSTOMER SERVICE SKILLS:
Willingness to provide a level of service which will clearly differentiate us from our competitors.
Professional demeanor in appearance, interpersonal relations, work ethic and attitude.
Ability to work under pressure.
Excellent interpersonal and written communication skills.
Effective organizational skills and promptness.
Ability to define problems, collect data, establish facts and draw conclusions.
Attention to critical details to properly document loans and modifications.
Ability to understand loan transactions.
Proficient in Microsoft Office, including Word, Excel and Outlook.
Possess accurate keyboarding skills.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Maintain working knowledge of commercial lending standards, banking laws and regulations, and bank credit policies and procedures as they related to business and/or commercial banking.
Accurately enter information and upload documents in workflow system, Finance Center, or other computer software utilized by the department.
Work with Closing Specialists and the Department Manager to ensure that all required information has been obtained.
Perform commercial loan documentation activities, including the preparation of LaserPro and other closing documents according to department standards and ensuring all terms and conditions are incorporated.
Prepare loan modification documents that are consistent with the Bank's credit policy.
Prepares boarding instructions for LaserPro and attorney prepared loan packages.
Ability to discuss issues with department manager or legal counsel to develop strategies and/or solutions.
Review loan files and understand the existing transaction in order to appropriately document a modification to the loan.
Banking is a highly regulated industry and you will be expected to acquire and maintain a proficiency in the bank's policies and procedures, and adhere to all laws, rules and regulations that are applicable to your conduct and the work you will be performing. You will also be expected to complete all assigned compliance training in a timely manner.
Manager-Clinical Documentation Improvement - Full Time - 8 Hour - Days*
The Manager of the Clinical Documentation Improvement (CDI) program is responsible for the development of a standardized, system-wide CDI program. The CDI Manager coordinates the activities of the CDI staff in evaluating medical record documentation to improve the accuracy and completeness of clinical documentation and data collection. The CDI Manager assists in the development of CDI tools and queries, leads initiatives, and is a subject-matter expert in CDI, managing the hospital CDI team and leading efforts in educating medical staff and other clinicians in clinical documentation requirements. The Manager creates, tracks, trends and reports on performance measures to assess the impact of clinical documentation improvement program. The Manager works corroboratively with service lines, medical staff and Epic Steering Committees to educate on the documentation requirements.
Bachelor of Science Accredited School of Nursing Required
Medical Degree Accredited School of Nursing Required
Master's Degree Health Services Administration Required
- 3 years Management
- Clinical Documentation Improvement Program Required
5 years Clinical Document Improvement in Acute Care Setting Required
- Electronic Health Records Required
- Certified Clinical Documentation Specialist Required
- Certified Coding Specialist (CCS) Preferred
- RN - Registered Nurse
- Current California License Required
Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting.
Extensive knowledge of all components related to clinical documentation.
Firm understanding of clinical processes (e.g. complications, co-morbidities, severity of illness, risk of mortality, case mix, and secondary diagnoses).
Demonstrated ability to integrate clinical and coding processes to improve health record integrity, regulatory compliance and reimbursement rates.
A high degree of organizational skills, ability to set priorities, manage multiple demands and the ability to complete tasks under strict time lines is required.
Exceptional writing skills.
Experience with coding.
Knowledge of ICD-10 coding and documentation principles.
Exempt Days (Mon-Fri) (United States of America)
Scheduled Weekly Hours
Sr. Manager, Partner Knowledge & Documentation
The Partner Operations group is one of the fastest growing, dynamic business units within the Walmart.com ecosystem. We enable the rapid growth of Walmart's digital business units through a maniacal focus delivering exceptional partner experiences & support for our Marketplace sellers, Drop Ship Vendors & Suppliers across both Walmart.com & Jet.com. This team is heavily involved in the effort to bring Walmart to the forefront of ecommerce and will continue to be a linchpin of the organization as we scale operations into the future.
The Senior Manager of Partner Knowledge & documentation is responsible for the development & creation of all Partner facing documentation & materials including, but not limited to email, program or policy language, surveys & partner portal verbiage. In addition to standardizing our go to market voice and Marketplace brand positioning, you will own the strategic direction of our Partner facing Knowledge Management environment and its continual evolution with the goal of delivering highly intuitive, exceptionally useful self-help solutions. This role requires a well-developed business acumen & must be highly effective in both day to day execution as well as defining & delivering against longer term strategic initiatives.
Requires close partnership with numerous internal business, technology & product teams, including especially close relationships with Partner Support & Legal. When appropriate, drives alignment across the business to ensure partner facing business units have absolute clarity & awareness on partner communications (e.g. call center, services centers, Category teams etc.)
End-to-end ownership of all content aspects of Knowledge Management ecosystem
Define success metrics and leverage analytics as well as user feedback to continually monitor knowledge management performance & drive continual improvement
Develop knowledge management strategies and operational processes to improve the learning and performance of users
Develop & establish mechanisms that fully support all aspects of the knowledge management life-cycle, including knowledge creation, storage, organization & distribution
Front line user communications, including email, video, Webinars, in-context solutions, chat support, etc
Manage a team responsible for daily Knowledge Management Activities such as:
Communications Workflow Management: Intake, Publication, QC and Maintenance
Knowledge Management Administration: End User Feedback, Workflow Administration, Data Architecture (taxonomy, metadata, tuning), Governance, Communications, Reporting
Minimum of 5 -7 years' experience leading Knowledge management initiatives in B2B & B2C applications
Demonstrated leadership experience and a history of productive collaboration & influence across all levels of an organization
Outstanding written & verbal communication
Excellent analytical, problem-solving and project leadership skills
Obsession for creating & delivering exceptional customer experiences
Certifications (preferred, but not required): Knowledge Management CKM/CKP, Knowledge Centered Support-KCS, Metadata and Taxonomy
Certifications in: Knowledge Management CKM/CKP, Knowledge Centered Support-KCS, Metadata and Taxonomy
Practical experience in Customer Service, Operations & technology environments
Background and/or certifications in continual improvement methodologies – i.e. Six Sigma
The Walmart US eCommerce team is rapidly innovating to evolve and define the future state of shopping. As the world's largest retailer, we are on a mission to help people save money and live better. With the help of some of the brightest minds in merchandising, marketing, supply chain, talent and more, we are reimaging the intersection of digital and physical shopping to help achieve that mission.
"I love that at Walmart, each associate has the opportunity and autonomy to create their own career path and grow." — Diane, Project Manager
Hello, Silicon Valley
You don't have to choose between your career and your lifestyle. In Silicon Valley, you can have both.
Discover Silicon Valley
- BeautyFioli Gardens, Woodside
View an art exhibit, take a nature hike, explore the historic Filoli House, or take a class at this gorgeous 654–acre property.
Get your art fix at this internationally recognized collection of over 30,000 works of modern and contemporary art.
- EducationComputer History Museum
Large-scale exhibits, an acclaimed speaker series, docent-led tours and an award-winning education program bring computer history to life.
- PurposeThe Dish
Hike or jog throughout the year on terrain dedicated to academic programs, environmental restoration and habitat conservation.
- ExploreGolden Gate Park, SF
Events, attractions, meadows, lakes, and a Japanese Tea Garden provide for a true escape, without leaving the city.
- ImagineThe Tech Museum
This family-friendly interactive science and technology center in San Jose provides a glimpse into the most inventive place on Earth — Silicon Valley.
- ShopSantana Row - San Jose
Stylish boutiques, world-class shopping, and delectable cuisine = a San Jose shopping trifecta.
- DisconnectPacifica State Beach
Learn to surf or visit the "World's Most Scenic Taco Bell" at this 0.75 mile long crescent shaped escape, a symbol of successful habitat restoration.
- ReflectGolden Gate Cemetery
This national cemetery comprises 161 acres dedicated to all the members of the armed forces who served our country.
All the benefits you need for you and your family
Multiple health plan options
Vision & dental plans for you & dependents
Associate discounts in-store and online
Financial benefits including 401(k), stock purchase plans and more
Education assistance for Associate and dependents
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On average, it takes 45-60 minutes to complete your application for the first time. Subsequent applications will take less time to apply as our system saves some of your application information. Please note that some positions require the completion of assessments in order to receive consideration for that role. Those would take additional time.
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No, you cannot change your application after submitting, so please make sure that everything is finalized before you hit the submit button.
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Processing of information on paper is minimal, and Walmart processes application information using an applicant tracking system (ATS). Access to the data within the ATS is restricted to authorized personnel, and the system itself is held to high security standards by Walmart.
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Clinical Documentation Specialist
- Part Time/Day Shift
Who We Are
We are a patient-focused, community-oriented hospital that is conveniently located in Montclair that is equipped with technology that rivals the nation's most prestigious healthcare systems. Hackensack Meridian Health Mountainside Medical Center offers a comprehensive and growing array of services delivered by caring and highly-skilled medical professionals. We're proud of the therapeutic and administrative upgrades we have made. Mountainside Medical Center has been serving Montclair and its surrounding New Jersey communities since 1891. The physicians, nurses and volunteers who are a part of the Mountainside family are your friends and neighbors. We're your community, your hospital and team, who will continue to work hard for you.
Hackensack Meridian Health Mountainside Medical Center is proud to continue to provide world-class health care services in a community setting. Our 365-bed medical center has successfully transitioned from a stand-alone facility to being part of Hackensack Meridian Health, the most comprehensive and truly integrated network in New Jersey. Mountainside is a joint venture between Hackensack Meridian Health and Ardent Health Services, one of the country's leading private hospital management companies.
We are looking for a dynamic and passionate Clinical Documentation Specialist to join the Mountainside Team!
What You'll Do
The Clinical Documentation Improvement (CDI) Specialist works collaboratively with medical, nursing, and coding staff to ensure accurate capture of clinical information through chart review, querying, and education.
The successful candidate will be able to:
Facilitate concurrent modifications to clinical documentation supporting specificity of services and care provided
Educate all internal customers, including physicians, nurses and other ancillary personnel, on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies
Create job aids and queries in support of training initiatives
Ensure the accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes as well as appropriateness of treatment setting
Conduct follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart
Review clinical issues with coding staff, nurses and other healthcare professionals as appropriate to ensure appropriate inpatient technical diagnosis and procedural coding
Discuss cases with physicians/provides, including periodic meetings, rounding and/or attending medical staff meetings
Inputs activities from concurrent reviews into CDI solution and ensures consistency of data captured
Serve as a member of the facility CDI Team and Documentation Improvement Work Group, providing input relative to documentation improvement processes and resources, and updates corporate HIM on facility coding/documentation improvement efforts
Perform any and all other duties as assigned
What You'll Bring
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What We Offer
Medical, dental, and vision insurance
401k with Company match
Company paid basic life insurance and long term disability coverage
Generous paid time off, including an additional extended illness bank
6 Paid Holidays
Advancement and career development opportunities
Hackensack Meridian Health Mountainside Medical Center is an Equal Opportunity Employer and applicants will receive consideration for employment regardless of race, color, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.
Documentation Quality Analyst
DescriptionJOB DESCRIPTION: Performs the function of regulatory record review and documentation assessment per state, federal, and regulatory requirements.
Reports documentation trends to management for the purposes of training and data validation. Trends documentation content for required components. Interprets data, analyzes results, and provides ongoing analytics for regulatory compliance.
May be asked to share results with other health system leaders. Performs the function of data analysis. Reviewing record content to discern trends and /data concerns.
Perform medical record chart completion analysis to determine compliance with Joint Commission Standards. Performs data monitoring of employee trends that are reported to the accountable manager. Also identify facility specific trends of data submission to entities such as the Georgia Hospital Association, The Joint Commission, and/or any other oversight entities.
Monitor facility specific medical staff bylaws for documentation compliance and report successes and failures to the appropriate entities for follow-up and corrective action. Provide education as to successful practices within the departments via staff actions and/or processes and share those with all members of our system for embrace when appropriate. Provide management group with trend insights across the entity inclusive of TEC, ESA, and PGP.
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Experience with Electronic Health Record. Must be competent in Excel. Great customer service and problem solving skills.
Experience in previous positions that required heighten attention to detail. PHYSICAL REQUIREMENTS (Medium): 20-50 lbs; 0-33% of the work day (occasionally); 11-25 lbs, 34-66% of the workday (frequently); 01-10 lbs, 67-100% of the workday (constantly); Lifting 50 lbs max; Carrying of objects up to 25 lbs; Occasional to frequent standing & walking, Occasional sitting, Close eye work (computers, typing, reading, writing), Physical demands may vary depending on assigned work area and work tasks. ENVIRONMENTAL FACTORS:
Factors affecting environment conditions may vary depending on the assigned work area and tasks. Environmental exposures include, but are not limited to: Blood-borne pathogen exposure Bio-hazardous waste Chemicals/gases/fumes/vapors Communicable diseases Electrical shock, Floor Surfaces, Hot/Cold Temperatures, Indoor/Outdoor conditions, Latex, Lighting, Patient care/handling injuries, Radiation, Shift work, Travel may be required. Use of personal protective equipment, including respirators, environmental conditions may vary depending on assigned work area and work tasks.
Business Specialist, Clinical Documentation Center
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– investigates and proactively resolved issues
– runs and performs review of reports and dashboards within eTMF
produces eTMF metrics
communicates to Master File owner(s) "root cause" analysis and potential data integrity concerns
Leads to completion of the final reconciliation/review and archival of individual master files, working closely with the Clinical Documentation Associate (CDA), CDC leadership and other TMF stakeholders (i.e., CPD, SM&M, DSS, BSO).
For CRO managed study TMFs: conduct QC of artifacts (may also include uploading and classifying); involvement with transfer of CRO TMFs into AbbVie eTMF system
Provides audit and inspection preparation support for paper and electronic TMFs, to include, but not limited to (on selected master files):
conduct data integrity checks
run & analyze reports for TMF completeness
work with the assigned CDA to follow-up on outstanding items with other functional areas
contribute to completion of pre-inspection requests
During an inspection:
function at the subject matter expert of the eTMF system navigation, including being present in the "front room" with the Auditors/Inspectors
participate in responding to auditor/inspector requests (may be required to put the response together)
Conduct TMF conversion activities; involvement with the transfer of TMFs from external entities (i.e., CRO, other pharmaceutical companies).
Provides suggestions for CDC work instructions/job aides and contributes to functional area continuous improvement projects and/or work streams.
Complies with GCP, AbbVie SOPs and functional area processes.
High school diploma or equivalent; Bachelor degree or international equivalent is preferred.
With at least 4 years of professional work experience.
Demonstrates analytical, critical thinking and organizational skills.
Ability to independently perform multiple tasks at the same time.
Good communication skills (oral and written)
Proven effective, collaborative interactions with colleagues
Experience working in electronic systems
Members of Clinical Documentation Center; Colleagues in Development and Global Medical Affairs responsible for contributing/owning master file artifacts.
At AbbVie, we value bringing together individuals from diverse backgrounds to develop new and innovative solutions for patients. As an equal opportunity employer, we do not discriminate on the basis of race, color, religion, national origin, age, sex (including pregnancy), physical or mental disability, medical condition, genetic information, gender identity or expression, sexual orientation, marital status, protected veteran status, or any other legally protected characteristic.
Significant Work Activities and Conditions: Continuous sitting for prolonged periods (more than 2 consecutive hours in an 8 hour day)
Travel: Yes, 10 % of the Time
Job Type: Experienced
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