Supervisor, Advanced Practice Provider - Critical Care - Full Time 12 Hours Rotating Shift (Exempt) (Non-Union)

Essential Job Functions and Core Responsibilities

• Aid in developing mechanisms to measure the effectiveness of healthcare programs.
• Develop and implement educational plans for physicians, nurses, and other clinical staff.
• Maintain productivity targets for record review and query placement.
• Apply ICD-10 CM and ICD-10-PCS coding conventions and guidelines to ensure accurate medical record documentation.
• Create and implement tools to support medical record documentation in collaboration with physician leadership.
• Facilitate multidisciplinary teams to improve clinical documentation practices.
• Identify strategies for sustaining work process changes that enhance clinical documentation.
• Ensure the quality and completeness of clinical documentation in accordance with regulatory requirements.
• Review inpatient medical records for identified payor populations upon admission and during hospitalization.
• Analyze patient clinical status, current treatment plans, and past medical histories to identify gaps in documentation.
• Collaborate with coding staff to ensure thorough documentation of discharge diagnoses and comorbidities.
• Work collaboratively with coding staff to assure documentation of discharge diagnoses and any coexisting/comorbidities accurately reflect the patient's clinical status and care.
• Perform other duties as assigned.

Job Requirements

• Education: Graduate from a nursing program, BSN, Health Information Management (RHIT, RHIA), or foreign medical doctorate degree, with accredited college courses in human anatomy, medical terminology, and disease processes.
• Experience: Extensive knowledge of ICD-10 CM and ICD-10-PCS coding, sequencing, and documentation guidelines; experience in CPT/HCPCS for hospital and/or clinic records; ability to initiate appropriate clinical documentation querying; strong background in pathophysiology and disease process; minimum of three years’ experience in clinical disciplines (RN, MD, FMG) or utilization review/case management in an acute care facility.
• Licenses and Certifications: Preferred certifications include Certified Coding Specialist (CCS), Certified Coding Associate (CCA), or Certified Documentation Improvement Practitioner (CDIP); Certified Clinical Documentation Specialist (CCDS) certification is highly desirable.

Pay

The hourly rate range for this position is $46.27 - $60.73. When extending an offer of employment, the University of Southern California Arcadia Hospital considers factors such as the scope and responsibilities of the position, the candidate’s work experience, education/training, key skills, internal peer equity, federal, state, and local laws, contractual stipulations, grant funding, as well as external market and organizational considerations.

Position Summary

The CDI Specialist is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness by improving the specificity of the physicians' clinical documentation. This involves extensive record review, interaction with physicians, HIM professionals, and nursing staff. The role also includes maintaining up-to-date information on Medicare, ICD-10, and CPT coding, and documentation guidelines. Active participation in team meetings to provide recommendations on query structure, process, and workflow. Responding to coding denials with clinical justifications and coding conventions. Maintaining confidentiality of patient, physician, associate, and adhering to HIPAA regulations. Keeping the CDI team and HIM Manager or Director informed of workflow status and potential backlog issues.