Clinical Documentation Integrity Specialist I, Relief

Job not on LinkedIn

🔥 0 minutes ago

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

Stanford Health Care

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1885

🏥 Healthcare

Healthcare

Stanford Health Care is a major academic medical center and integrated hospital system delivering comprehensive clinical care, specialty services, and patient support. The organization operates hospitals, outpatient clinics and programs, offers clinical trials and telehealth (video visits), and provides patient-facing services such as a MyHealth patient portal, billing/insurance assistance, and resources for referring physicians, nurses and allied health professionals. It also engages with the community through donations, visitor services, and COVID-19 resources.

📋 Description

• 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