Clinical Documentation Integrity Specialist I, Relief

Stanford Health Care

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.

Posted 8/10/2026part-timeRemote • 🇺🇸 United StatesMid-LevelSenior💰 $56 - $74 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical documentation improvement, coding guidelines, and healthcare regulations, with a strong ability to analyze data and enhance documentation quality. Proficient in managing multidisciplinary projects and fostering collaborative relationships with clinical providers.

Highest-signal resume keywords

Clinical Documentation Improvement (CDI)ICD-10-CM/PCS CodingMS-DRGs and APR-DRGs KnowledgeProject ManagementStrong Verbal and Written Communication

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Documentation ReviewCoding Guidelines ApplicationData AnalysisDocumentation Improvement InitiativesHealthcare Regulations Knowledge

Soft Skills

Judgment and Decision-MakingOrganizational SkillsAdaptabilityCollaborationProblem-Solving

Tools & Technologies

Microsoft Office Suite3M EncoderEpic Electronic Health Record Systems

Certifications & Qualifications

RN State LicensureAHIMA and ACDIS Ethical Standards Knowledge

Industry Keywords

Inpatient Clinical ExperienceCase ManagementUtilization ReviewProvider InteractionCMS Coding Guidelines

About the role

Key responsibilities & impact

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

What you’ll need

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

Comp & perks

Non-benefitted role (no employer benefits are specified)
Remote work arrangement