Clinical Documentation Integrity Specialist I, Relief
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Job Description
Clinical Documentation Integrity Specialist improving medical-record accuracy, severity capture, and coding compliance for Stanford Health Care. Reviewing records, querying physicians, and partnering with coding teams on patient outcomes and reimbursement.
Responsibilities:
- Conduct concurrent and retrospective clinical documentation reviews of inpatient and/or outpatient medical records
- Identify opportunities to improve the quality and completeness of clinical documentation
- Facilitate and obtain physician documentation supporting severity of illness, expected risk of mortality, complexity of care, coding, and outcomes
- Initiate medical record reviews within 24 to 48 hours of admission and monitor targeted records within at least 48 hours
- Conduct follow-up reviews and ensure clarifications are addressed in the medical record
- Apply coding policies, reimbursement guidelines, Coding Clinic Guidelines, MS-DRGs, APR-DRGs, HCCs, ICD-10-CM/PCS, and AMA CPT conventions to assign working and final DRGs
- Partner with inpatient coding staff to ensure diagnostic and procedural data accuracy and documentation completeness
- Advise and counsel clinical providers on documentation, coding concepts, and query procedures
- Maintain liaison relationships with assigned departments and service lines
- Query physicians regarding ambiguous, missing, conflicting, or abnormal clinical information, including through face-to-face interactions and rounding
- Assist CDI service line teams and leadership with documentation evaluations and improvement initiatives
- Perform ongoing documentation analysis and submit clarifications or queries to mitigate gaps and inconsistencies
- Assist peers and leadership in understanding variance and CDI-related barriers
- Recommend improvements to documentation tools, provider engagement, and related processes
- Reconcile query and non-query impact in CDI data-entry systems
- Manage projects involving clinical documentation initiatives, scope expansion, and opportunity identification
Requirements:
- Bachelor’s degree in Nursing, Medicine, Health Information Management, or a similarly related field, or equivalent combination of education and experience
- Five (5) years of progressively responsible and directly related inpatient clinical experience
- 0–2 years of CDI-related work experience
- ICU/ED and Academic Medical Center experience preferred
- Case management, utilization review, and/or direct provider interaction experience preferred
- Knowledge of AHIMA and ACDIS Ethical Standards
- Knowledge and application of CMS coding guidelines and methodologies, MS-DRGs, APR-DRGs, HCCs, ICD-10-CM/PCS, and AMA CPT coding guidelines and conventions
- Ability to stay current with CMS rules and regulations
- Ability to analyze problems, data, and reporting systems and develop solutions or process improvements
- Ability to exercise judgment, make informed decisions, organize and prioritize work, multitask, adapt to changing priorities, and meet deadlines
- Ability to manage projects involving multidisciplinary teams and workflows
- Ability to create, deliver, and manage clinical documentation education content
- Proficiency with Microsoft Office Suite, including word processing, spreadsheets, and presentation software
- Knowledge of analytical research procedures and methods
- Ability to perform testing, data auditing, and implementation of CDI and coding software or documentation processes
- Ability to develop and maintain collaborative relationships with physicians and clinical professionals
- Strong verbal and written English communication skills; mastery of verbal and written English communication
- Beginning to intermediate MS Office Suite proficiency; intermediate to advanced proficiency also listed
- Some exposure to an encoder and/or electronic health record systems; exposure to or experience with 3M encoder and/or Epic electronic health record systems
- RN state licensure and/or compact state licensure preferred
Benefits:
- Non-benefitted role (no employer benefits are specified)
- Remote work arrangement
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