CDI Specialist I: Clinical Documentation & Coding

LE0010 Stanford Health Care; United States; Remote; USD 160,198,000 - 212,040,000; Full time

Job summary

Stanford Health Care is seeking an entry-level Relief Clinical Documentation Integrity Specialist I to review clinical documentation across inpatient and outpatient records, driving accuracy in severity of illness, mortality risk, and care complexity. You will learn to engage providers, query appropriately, and contribute to documentation integrity initiatives within a structured supervision framework.

As a trainee CDI role, you will develop expertise in AHIMA/ACDIS guidelines, CMS coding norms,

Qualifications

• Bachelor’s degree in Nursing, Medicine, Health Information Management or related field.
• Five (5) years of inpatient clinical experience.
• 0–2 years of CDI-related work experience (ICU/ED and Academic Medical Center preferred).

Responsibilities

• Reviews inpatient and outpatient records to improve documentation quality.
• Queries physicians to clarify documentation for accurate coding.
• Ensures DRGs and LOS reflect patient complexity.
• Partners with CDI team to implement improvement initiatives.

Skills

Clinical documentation knowledge

Coding knowledge

Medical record review

Physician query process

Regulatory knowledge

Education

Bachelor's degree in Nursing/Health Information Management

RN licensure

Tools

Epic EHR

3M Encoder

Job description

Stanford Health Care is seeking an entry-level Relief Clinical Documentation Integrity Specialist I to review clinical documentation across inpatient and outpatient records, driving accuracy in severity of illness, mortality risk, and care complexity. You will learn to engage providers, query appropriately, and contribute to documentation integrity initiatives within a structured supervision framework.

As a trainee CDI role, you will develop expertise in AHIMA/ACDIS guidelines, CMS coding norms,