Clinical Documentation Integrity Lead - Service Line (Remote)

Stanford Health Care • Hubley Township, PA

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 works directly with service line leaders to improve query turnaround, identify and facilitate targeted education, and strengthen engagement and buy-in.

The lead manages relationships between CDI and assigned service lines, regularly meeting with physician champions and chairs or chiefs. The role conducts targeted audits and analyzes findings to identify documentation and coding opportunities, assess compliance risks, develop education, and support short- and long-term improvements. It also coordinates data collection and analysis with quality teams, leads multidisciplinary projects and working sessions, and partners with CDI, IT, and technology teams to optimize documentation tools and processes.

The position serves as a subject matter expert on CDI practices, coding rules and regulations, and documentation opportunities. It monitors CDI and coding quality, contributes to project reviews, provides feedback to peers and partners, and develops, delivers, and evaluates provider and multidisciplinary education. The role is remote and based in the United States.

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 regulatory changes into practice.
• Extensive knowledge and experience with computer systems, reporting software, and electronic medical record systems used in the functional area.
• Demonstrated leadership ability, organizational savviness, and critical thinking skills.
• Ability to develop and maintain 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 deliver high-profile projects within schedule and budget.
• Knowledge of statistical analysis and reporting practices for quality improvement and program evaluation.
• Ability to work independently and creatively in a high-volume, fast-paced, and politically complex 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.
• Nursing/RN state or compact-state licensure is preferred.

Nice To Haves

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

Responsibilities

• Manage and optimize relationships between CDI and assigned service lines, meeting regularly with service line physician champions and chairs or chiefs.
• Monitor queries and escalate them as appropriate to improve workflow efficiency and turnaround.
• Conduct targeted CDI audits and analyze documentation and coding findings to identify individual and service line opportunities, develop physician education, and facilitate resolutions.
• Serve as a subject matter expert on CDI practices, coding rules and regulations, and assess potential or identified compliance deficiencies 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 with quality teams regarding patient care activities, documentation and coding opportunities, and clinical outcome performance gaps.
• Coordinate multidisciplinary working sessions for goal setting and problem solving.
• Optimize service line CDI programs, including creating, delivering, and evaluating 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 documentation quality and integrity.

What This Job Offers

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