Clinical Documentation Integrity Lead – Service Line

🔥 17 hours ago

🏄 California – Remote

🏄 California – Remote

💵 $72 - $96 / hour

⏰ Full Time

🟠 Senior

🏥📝 Medical Writer

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Stanford Health Care

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1885

🏥 Healthcare

⚕️ Healthcare Insurance

📚 Education

Healthcare • Healthcare Insurance • Education

Stanford Health Care is a major academic medical center affiliated with Stanford Medicine. It provides world-renowned patient care, emphasizes innovation and research, and offers a wide range of clinical services and career opportunities across nursing, advanced practice, allied health, laboratory, technology, administration, and other areas. The organization promotes values such as C-I-CARE (respect, courtesy, personal connection), sustainability, dedication, and community collaboration across physicians, researchers, professors, and students to advance health, healing, and knowledge globally.

📋 Description

• Manage and optimize relationships between CDI and assigned service lines, meeting regularly with 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, identify individual and service-line opportunities, and facilitate short- and long-term resolutions • Serve as a subject matter expert on CDI practices, coding rules and regulations, compliance risks, and 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 activities, documentation and coding opportunities, 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 to achieve strategic goals • Partner with CDI leads, IT, and technology partners to optimize documentation tools and processes and reduce provider administrative burden

🎯 Requirements

• Bachelor’s degree in Nursing, Medicine, Health Information Management or a similarly related field of study • At least two currently active certifications from the listed certification categories, including COC, CPC, CCS, CDMP, CAP, CRCR, HACP, CPHQ, HCQM, CCM, clinical certification, PECP, or other education certification • Five years of progressively responsible and directly related inpatient clinical experience • At least five years of CDI or provider education-related work experience • Experience with outcomes data reporting and analysis • At least one currently active CCDS, CCDS-O, or CDIP certification • Expertise in coding and CDI practices, Medicare/Medicaid rules and regulations, CMS coding guidelines, MS-DRGs, APR-DRGs, HCCs, ICD-10-CM/PCS, and AMA CPT coding guidelines • Extensive knowledge and experience with computer systems, reporting software, and electronic medical record systems • Leadership, organizational, critical thinking, interpersonal, verbal, and written communication skills • Knowledge of project management, statistical analysis, quality improvement, and program evaluation • Ability to develop and deliver training and education to clinical, CDI, and coding professionals • ICU/ED and Academic Medical Center experience preferred • Case management, utilization review, direct provider interaction, public speaking, and multidisciplinary education experience preferred • Experience with Vizient, Premier, Elixhauser, and other risk adjustment methodologies highly preferred • Nursing/RN state or compact-state licensure preferred

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