Clinical Documentation Integrity Lead - Service Line (Remote)

Stanford Health Care

7d • $73 - $96 • Remote

About The Position

The Clinical Documentation Integrity (CDI) Service Line Outcomes Lead partners with service line and physician leadership to optimize documentation tools, improve processes, and develop strategies that reduce administrative burden on providers while maintaining high-quality, integrity-focused documentation. The role directly partners with service line leaders to improve query turnaround, identify and facilitate targeted education opportunities, and strengthen engagement and buy-in.

The lead serves as a subject matter expert in CDI practices, coding rules and regulations, and documentation opportunities. The role works with multidisciplinary teams, quality teams, CDI and coding colleagues, IT, and other technology partners to improve service-line outcomes and documentation processes. This is a remote Stanford Health Care position with a day shift and an eight-hour schedule.

Requirements

• Bachelor’s degree in Nursing, Medicine, Health Information Management, or a similarly related field.
• At least two currently active certifications from the following categories: COC, CPC, or CCS; CDMP, CAP, or similar; CRCR or another revenue cycle certification; HACP, CPHQ, HCQM, or another health care quality certification; CCM or a clinical certification; PECP or another education certification.
• At least 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 certification: CCDS, CCDS-O, or CDIP.
• Expertise in coding and CDI practices, including Medicare and Medicaid rules and regulations and current trends and developments.
• Knowledge of CMS coding guidelines and methodologies, MS-DRGs, APR-DRGs, HCCs, current CM/PCS and AMA CPT coding guidelines and conventions, and the ability to incorporate CMS regulatory changes into daily practice.
• Extensive knowledge and experience with computer systems, reporting software, and electronic medical record systems used in the functional area.
• Demonstrated leadership ability, organizational savvy, and critical-thinking skills.
• Ability to develop and maintain strong, collaborative working relationships with peers, physicians, and other clinical professionals.
• Demonstrated interpersonal, verbal, and written communication skills for working with multidisciplinary teams and managing ongoing activities.
• Knowledge of project-management processes and systems, with the ability to lead teams and manage high-profile projects to schedule and budget.
• Knowledge of statistical analysis and reporting practices related to quality improvement and program evaluation.
• Ability to work independently, creatively, and with an innovation focus in a high-volume, fast-paced, and highly political work environment, with minimal supervision and strong self-motivation.
• Expertise in developing and delivering training and education to clinical, CDI, and coding professionals on CDI practices, coding, and documentation requirements, and distributing knowledge to multidisciplinary teams.

Nice To Haves

• ICU or ED experience.
• Academic Medical Center experience.
• Case management, utilization review, or direct provider interaction experience.
• Experience in public speaking and creating and delivering formal multidisciplinary education.
• Experience with Vizient, Premier, Elixhauser, and other risk-adjustment methodologies (highly preferred).
• Nursing/RN state licensure and/or compact-state licensure (preferred).

Responsibilities

• Manage and optimize positive relationships between CDI and assigned service lines, meeting regularly with the service line physician champion and chair/chief.
• Drive workflow efficiency by monitoring queries and escalating them as appropriate.
• Conduct targeted CDI audits and analyze findings related to documentation and coding to develop physician education, identify individual and service-line opportunities, and facilitate short- and long-term resolutions.
• Serve as a subject matter expert and authoritative resource on CDI practices, coding rules and regulations; assess risks related to potential and detected compliance deficiencies and documentation opportunities in assigned service lines.
• Monitor and evaluate CDI and coding quality against best practices, complete project-related reviews, and provide relevant feedback to peers, coding, CDI leadership, and quality partners as needed.
• Coordinate data collection and analysis with quality teams concerning patient care activities, documentation and coding opportunities, and clinical outcome performance gaps.
• Coordinate multidisciplinary team working sessions for goal setting and problem solving.
• Optimize service-line CDI programs, including creation, delivery, and evaluation of provider and multidisciplinary education.
• Lead multidisciplinary and multi-departmental CDI projects to achieve strategic goals and objectives.
• Partner with other CDI leads, IT, and technology partners to create and optimize documentation tools, processes, and strategies that reduce provider administrative burden while maintaining high-quality, integrity-focused documentation.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior