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Clinical Documentation Integrity Specialist I, Relief, Non-benefitted
Stanford Health CareClinical Documentation Integrity Specialist improving inpatient and outpatient records for Stanford Health Care. Reviewing documentation, coding, physician queries, and DRGs to support accurate healthcare outcomes.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical documentation integrity (CDI) through effective evaluation and improvement of medical records, ensuring compliance with coding guidelines and enhancing documentation quality. Proficient in managing multidisciplinary projects and fostering collaborative relationships with clinical providers to optimize documentation practices.
Highest-signal resume keywords
Clinical Documentation Integrity (CDI)ICD-10-CM/PCS CodingMS-DRGs and APR-DRGs KnowledgeRegulatory Compliance AnalysisProject Management
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
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Hard Skills
Clinical Documentation ReviewCoding Guidelines ApplicationData AuditingDocumentation Quality ImprovementAnalytical Research Procedures
Soft Skills
Communication of Complex ConceptsProblem Analysis and RecommendationOrganizational and Multitasking AbilitiesCollaboration with Clinical Professionals
Tools & Technologies
Microsoft Office SuiteElectronic Health Record SystemsCDI and Coding Software
Certifications & Qualifications
RN State LicensureAHIMA and ACDIS Ethical Standards Knowledge
Industry Keywords
Inpatient Clinical ExperienceUtilization ReviewCase ManagementProvider EngagementDocumentation Standards
About the role
Key responsibilities & impact- Conduct concurrent and retrospective reviews of inpatient and/or outpatient medical records
- Evaluate clinical documentation and identify opportunities to improve documentation quality
- Facilitate and obtain physician documentation supporting severity of illness, expected risk of mortality, and complexity of care
- Initiate medical record reviews within 24 to 48 hours of admission
- Monitor targeted medical records for compliance with documentation standards
- Conduct follow-up reviews to ensure clarifications are documented
- Apply coding policies, reimbursement guidelines, and Coding Clinic Guidelines to assign working DRGs
- Partner with inpatient coding staff to ensure accurate diagnostic and procedural data and complete supporting documentation
- Advise and counsel clinical providers on documentation, coding concepts, and query processes
- Initiate physician interactions and queries for ambiguous, missing, or conflicting information
- Contribute to provider engagement and documentation integrity improvement initiatives
- Analyze documentation performance and submit clarifications or queries to address gaps and inconsistencies
- Assist peers and leadership with documentation and CDI-related barriers and variance analysis
- Recommend improvements to documentation tools, provider engagement, and processes
- Reconcile query and non-query impact in CDI data entry systems
- Manage projects involving clinical documentation initiatives and analyze potential scope expansion or opportunities
Requirements
What you’ll need- Bachelor’s degree in Nursing, Medicine, Health Information Management, a similarly related field, or equivalent combination of education and experience
- Five 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 of CMS coding guidelines and methodologies, MS-DRGs, APR-DRGs, HCCs, ICD-10-CM/PCS, and AMA CPT coding guidelines and conventions
- Ability to analyze problems and understand regulatory and reimbursement impacts
- Knowledge of local, state, and federal regulatory requirements related to the functional area
- Ability to analyze information, reach valid conclusions, and make sound recommendations
- Ability to communicate complex concepts to non-CDI or Revenue Cycle experts
- Ability to manage, organize, prioritize, multitask, adapt to priorities, and meet deadlines
- Ability to manage projects involving multidisciplinary teams and workflows
- Ability to provide concise reports of activities and results
- Ability to create, deliver, and manage educational content related to clinical documentation integrity
- Proficiency with Microsoft applications, including word processing, spreadsheets, and presentation software
- Knowledge of analytical research procedures and methods
- Ability to assess reporting systems and develop process and procedural improvements
- 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 other clinical professionals
- Mastery of verbal and written English communication
- Beginning to intermediate Microsoft Office Suite proficiency
- Some exposure to an encoder and/or electronic health record systems
- RN state licensure and/or compact state licensure preferred
Benefits
Comp & perks- Remote work arrangement
- Part-time schedule
- Non-benefitted role (no benefits stated)