Supervisor, Clinical Doc Integrity - Clinical Doc Integrity - Full Time 8 Hour Days (Exempt) (Non-Union)

University of Southern California•Alhambra, CA

5d•$110,240 - $181,896

About The Position

The Clinical Documentation Improvement (CDI) Supervisor will have an integral part of the departmental leadership team in overseeing the daily operations of the CDI program. This position utilizes clinical knowledge, ICD coding expertise, and an understanding of regulatory guidelines to ensure accurate, complete, and compliant clinical documentation that supports appropriate reimbursement and reflects the quality of patient care. The CDI Supervisor provides day-to-day direction and mentoring to Clinical Documentation Specialists (CDSs), assisting with work assignments, case review prioritization, and adherence to departmental policies and standards. In collaboration with CDI leadership, the Supervisor participates in onboarding, training, and ongoing education to strengthen staff competency, compliance and performance. This role will have an instrumental role in the preparation of audit readiness and in the review and analysis of CDI performance metrics and documentation audits. The Supervisor collaborates closely with HIM, Coding, Quality, and Compliance departments to promote best practices in provider documentation, maintain regulatory compliance, and achieve CDI program goals. The CDI Supervisor serves as a liaison between CDI staff and leadership, facilitating communication, identifying process improvement opportunities, and ensuring that CDI operations align with organizational standards and enterprise objectives.

Requirements

Graduate of an accredited school of registered nursing and/or foreign medical graduate.
2 years Experience in a lead/supervisory capacity Clinical Documentation Specialist role
3 years Clinical experience in an acute care setting
Advanced clinical expertise and extensive knowledge of complex disease processes with broad based clinical experience in an inpatient setting
Knowledge of care delivery documentation systems and related medical record documentation.
Strong broad based clinical knowledge and understanding of pathology/physiology of disease processes.
Expertise on: ICD10 CM & PCS, coding clinic and Official Guidelines for Coding and Reporting, Risk and Severity-Stratification Models: MS-DRG,APR-DRG, HCC, Quality metrics: Patient Safety Indicators (PSIs), Mortality Index, Hospital Acquired Conditions (HACs), and AHIMA and ACDIS CDI regulations, standards and code of ethics
Proficiency with Microsoft Applications, including word processing, spreadsheets and presentation software
Extensive knowledge and experience in reporting software and electronic medical record systems
Demonstrated leadership ability
Maintains working knowledge of Medicare/Medicaid rules and regulations regarding CDI, POA (present on admission), basic coding, as well as current trends and developments in the area of Clinical Documentation Improvement (CDI)
Ability to work with senior management, physicians, and medical center staff with various levels of education and experience
Ability to develop and maintain strong, collaborative and supportive working relationships with CDI peers, physicians and other clinical professionals
Must have demonstrated interpersonal, verbal and written communication skills in dealing with multidisciplinary teams and variety of ongoing activities
Knowledge of computer systems and software used in functional area
Knowledge of project management processes and systems
Knowledge of statistical analysis and reporting practices pertaining to quality improvement and program evaluation
Demonstrated organizational, project management skills
Ability to be creative and innovative in a high volume work environment
Ability to communicate effectively, both orally and in writing
Ability to lead teams and produce project results within schedule and budget
Ability to plan, organize, motivate, mentor, direct and evaluate the work of others
Ability to provide leadership and influence others
Ability to work effectively with individuals at all levels of the organization
Ability to work independently
Skilled and experienced in data analysis and qualitative reporting of results
Skill in developing and delivering training and education to clinical, CDI and coding professionals regarding CDI practices, coding and documentation requirements
Demonstrated organizational and critical thinking skills, ability to assess, evaluate and teach
Skilled in adaptability and self-motivation in staying abreast of CDI practices, coding changes and clinical practices
Demonstrated judgment and independent decision making
Ability to motivate, train and teach individuals; demonstrated skills in interpersonal relationships and in oral and written communication. Ability to analyze and prioritize work efforts and organize and coordinate multiple functions and tasks.

Responsibilities

Partner with CDI Manager and Director in coordinating daily CDI operations to meet departmental and organizational goals.
Monitors workflow processes, concurrent review assignments, and case distribution to ensure timely, accurate, and compliant documentation review activities.
Supports the development and execution of the annual CDI work plan and contributes to routine operational and performance reports.
Provides day-to-day guidance, mentoring, and support to CDI Specialists and new team members.
Collaborate with departmental leadership in the development, implementation, and delivery of CDI education and training programs for staff, providers, and other stakeholders.
Identifies educational needs through audit findings and collaborates with leadership to design and facilitate targeted training and documentation improvement sessions.
Performs case reviews and quality audits to ensure completeness, accuracy, and clinical validity of documentation and code assignments.
Tracks and trends audit outcomes, identifies performance opportunities, and works with leadership to implement corrective action plans.
Supports audit readiness and participates in ongoing quality improvement initiatives related to CDI, coding, and clinical documentation compliance.
Collaborates with HIM, Coding, Quality, Compliance, and Performance Improvement teams to maintain consistency in documentation practices, promote best practices across disciplines, and make recommendations as needed.
Serves as a liaison between CDI staff and leadership, ensuring timely communication of updates, performance data, and documentation-related initiatives.
Supports provider education by facilitating discussions on documentation requirements, query response expectations, and clinical specificity.
Provides feedback and collaborates with medical staff to enhance the accuracy and completeness of the medical record.
Assists with the collection, tracking, and analysis of CDI metrics, including productivity, query response rates, case mix index (CMI), and quality indicators.
Prepares and distributes reports that support performance monitoring, compliance tracking, and program improvement initiatives.
Responds to clinical documentation or clinical validation denials and provide CDI leadership with updates and request for escalation as needed
Reviews relevant documentation and coding to identify root causes, assists in preparing appeals, and recommends process improvements to minimize future denials.
Participates in the review and development of CDI policies, procedures, and training materials and make recommendations as needed.
Assists in maintaining program compliance with federal and state regulations, AHIMA and ACDIS guidelines, and institutional standards.
Performs other related duties as assigned to support the goals and success of the CDI program.