Clinical Documentation Integrity Lead – Service Line
Employment Information
Report this job
Job expired or something wrong with this job?
Job Description
Clinical Documentation Integrity Lead optimizing CDI programs, coding quality, and provider education at Stanford Health Care. Partnering with physicians, service lines, IT, and quality teams to improve outcomes.
Responsibilities:
- Partner with service line and physician leadership to optimize documentation tools, improve processes, and reduce provider administrative burden
- Manage and optimize relationships between CDI and assigned service lines
- Meet regularly with service line physician champions and chairs/chiefs
- Monitor and escalate queries to improve workflow efficiency and query turnaround
- Perform targeted CDI audits and analyze findings related to documentation and coding
- Build physician education and identify individual and service line opportunities
- Serve as a subject matter expert on CDI practices, coding rules and regulations
- Conduct compliance risk assessments and identify documentation opportunities
- Monitor and evaluate CDI and coding quality against best practices
- Complete project-related reviews and provide feedback to peers, coding, CDI leadership and quality partners
- Coordinate data collection and analysis related to patient care, documentation, coding and clinical outcome gaps
- Coordinate multidisciplinary working sessions for goal setting and problem solving
- Optimize service line CDI programs and create, deliver and evaluate provider and multidisciplinary education
- Lead multidisciplinary and multi-departmental CDI projects
- Partner with CDI leads, IT and technology partners to create and optimize documentation tools, processes and strategies
Requirements:
- Bachelor’s degree in Nursing, Medicine, Health Information Management or similarly related field of study
- At least two currently active certifications from the listed certification categories
- At least 5 years of progressively responsible and directly related inpatient clinical experience
- At least 5 years of CDI, or provider education related work experience
- Outcomes data reporting and analysis experience
- Expertise in coding and CDI practices
- Expertise in Medicare/Medicaid rules and regulations
- Knowledge of CMS coding guidelines and methodologies, MS-DRGs, APR-DRGs, HCCs, CM/PCS and AMA CPT coding guidelines
- Extensive knowledge and experience in computer systems, reporting software and electronic medical record systems
- Demonstrated leadership ability, organizational savviness, and critical thinking skills
- Strong collaborative, interpersonal, verbal and written communication skills
- Knowledge of project management processes and systems
- Knowledge of statistical analysis and reporting practices
- Expertise in developing and delivering training and education
- At least one currently active certification: CCDS or CCDS-O or CDIP
- ICU/ED and Academic Medical Center experience preferred
- Case management, utilization review and/or direct provider interaction experience preferred
- Public speaking and formal multidisciplinary education experience preferred
- Experience with Vizient, Premier, Elixhauser and other risk adjustment methodologies highly preferred
Similar Jobs
Sponsor Dedicated Protocol Medical Writer II
Medical writer developing clinical protocols and regulatory documents for Syneos Health’s biopharmaceutical solutions. Coordinating reviews, regulatory compliance, and cross-functional study deliverables.
Radiation Therapy Clinical Documentation Auditor
Radiation therapy documentation auditor reviewing records and charges for Baptist Health, a major South Florida healthcare system. Supporting coding accuracy, reimbursement, authorizations, and staff education.
Clinical Documentation Integrity Analyst
Remote Clinical Documentation Integrity Analyst training CDI specialists and reviewing records for accurate acuity, mortality risk, and DRG capture. Supporting University Hospitals’ revenue-cycle and quality initiatives.
Senior Medical Copywriter
Senior Medical Copywriter creating branded HCP and medical education content for Orchard’s US pharmaceutical clients. Translating complex science into accurate, FDA-compliant campaigns.
RN Nurse, Clinical Documentation Improvement Specialist
Clinical Documentation Improvement Specialist reviewing inpatient records and physician documentation for R1’s healthcare revenue-cycle technology. Improving coding accuracy, severity capture, and compliance.
Medical Writer III, Pharmacovigilance
Medical Writer III authoring regulatory pharmacovigilance documents for PrimeVigilance, a global patient-safety specialist. Analysing safety data, supporting clients, and mentoring junior medical writers.
Medical Writer III, Pharmacovigilance
Medical Writer III creating regulatory pharmacovigilance documents for PrimeVigilance, a global patient-safety specialist. Analysing safety data, supporting clients, and mentoring junior medical writers.
Principal Medical Writer – Regulatory Submission
Medical writer developing global regulatory submissions for Syneos Health’s biopharmaceutical clients. Managing cross-functional timelines, quality documents, process improvements, and junior writer mentorship.
Senior Medical Writer – FSP
Senior Medical Writer producing clinical and regulatory documents for Syneos Health, a life sciences services organization. Leading cross-functional medical writing, reviews, and client deliverables.
Medical Writer
Medical Writer authoring clinical and regulatory documents for Quanticate, a global data-focused CRO. Leading projects, supporting clients, and mentoring writers across clinical development programmes.
Senior Medical Writer
Senior Medical Writer creating clinical documents and scientific communications for ICON, a global healthcare intelligence and clinical research organisation. Supporting late-phase projects and client account teams.
Medical Copywriter
Medical copywriter translating complex pharmaceutical science into promotional content. Developing compliant campaigns for HCPs, patients, and global healthcare brands at Greenpark.
Senior Medical Writer
Senior Medical Writer creating clinical and regulatory documents for Syneos Health’s life sciences research services. Coordinating reviews, regulatory compliance, and cross-functional study deliverables.
Senior Medical Copywriter
Senior Medical Copywriter creating HCP campaigns and medical education content for Orchard, a medical communications agency. Translating complex science into accurate, FDA-compliant copy for US pharmaceutical clients.
Sponsor Dedicated Protocol Medical Writer II/Sr
Medical Writer developing clinical protocols and regulatory documents for Syneos Health’s life sciences clients. Partnering with Clinical Scientists across oncology, hematology, and cell therapy studies.
Senior Clinical Documentation Improvement Specialist
Senior CDI Specialist improving inpatient medical-record documentation integrity at Mercy. Reviewing records, educating providers, and supporting healthcare quality and compliance initiatives.
RN – Clinical Documentation Integrity Specialist
RN CDI Specialist reviewing inpatient records, clarifying diagnoses, and supporting DRG accuracy for Carle Health. Educating clinicians and contributing to coding, quality, and compliance initiatives.
Clinical Documentation Specialist
Clinical Documentation Specialist reviewing inpatient records for MercyOne Genesis healthcare. Ensuring accurate clinical severity, mortality risk, quality indicators, and service-level documentation.
Clinical Documentation Specialist
Clinical Documentation Specialist reviewing inpatient records for accuracy and completeness at MercyOne Genesis. Educating providers and querying documentation to support compliant patient-care coding.
Senior Strategic Medical Writer
Senior Strategic Medical Writer leading clinical and regulatory documentation for AbbVie’s drug and device development. Coordinating reviews, quality control, submission strategies, and inspection-ready responses.