Clinical Documentation Integrity Lead - Service Line (Remote)

Stanford Health Care; United States; Remote; USD 101,000 - 132,000; Full time

Job summary

Stanford Health Care seeks a Clinical Documentation Integrity (CDI) Service Line Outcomes Lead to partner with service line and physician leadership. You will optimize documentation tools, improve processes, and reduce administrative burden while maintaining high-quality, compliant documentation.

The role focuses on improving query turnaround, targeted education, and engagement across service lines, with emphasis on CDI best practices and risk assessment.

Qualifications

• Bachelor’s degree in a related field is required.
• Active clinical certifications or coding certifications are required.
• Experience with CDI and coding practice guidelines is essential.
• Strong knowledge of CMS coding rules and risk adjustment methods.
• Proven leadership and education development capabilities.
• Ability to conduct audits and provide targeted education.

Responsibilities

• Manage CDI relationships with service lines and physician leaders.
• Drive workflow efficiency by monitoring CDI queries and escalation.
• Perform targeted audits and analyze findings to educate providers.
• Serve as SME on CDI practices, coding rules, and risk assessments.
• Monitor CDI and coding quality and provide feedback to teams.
• Coordinate data collection with quality teams on care activities.
• Lead multi-disciplinary sessions for goal setting and problem solving.
• Develop and evaluate education content for CDI and coding teams.
• Lead CDI projects to meet strategic objectives.
• Collaborate with IT to optimize documentation tools and processes.

Skills

Leadership

Project management

Public speaking

Education design

Education

Bachelor’s degree in Nursing, Medicine, Health Information Management or related field

CCDS - Cert Clinical Document Specialist

CCDS-O / CDIP certification

CRCR or revenue cycle certification

HACCP/CPHQ or HCQM related certification

CCM or clinical certification

Tools

Vizient

Elixhauser

CMS coding guidelines

Job description

If you’re ready to be part of our legacy of hope and innovation, we encourage you to take the first step and explore our current job openings. Your best is waiting to be discovered.

Day - 08 Hour (United States of America)

This is a Stanford Health Care job.

A Brief Overview

The Clinical Documentation Integrity (CDI) Service Line Outcomes Lead is responsible for partnering with service line & physician leadership to optimize documentation tools, improve processes, and develop strategies to reduce administrative burden on our providers, while maintaining high quality and integrity documentation. This leader will serve as a direct partner to service line leaders with the aim to improve query turnaround, identify & facilitate targeted education opportunities, and strengthen overall buy-in and engagement.

Locations

Stanford Health Care

What you will do

• Responsibility for management and optimization of the positive relationships between CDI and the service lines assigned, meeting regularly with SL Physician Champion and Chair/Chief.
• Drive increased workflow efficiency through monitoring and escalating queries as appropriate.
• Performance of CDI targeted audits and analysis of the findings, related to documentation and coding, to build physician education, identify areas of individual and service line opportunity, and facilitate short and long-term resolutions.
• Serve as a subject matter expert and authoritative resource on interpretation and application of CDI practices, coding rules and regulations, and conducts risk assessments of potential and detected compliance deficiencies, as well as documentation opportunities within the service lines assigned.
• Assists in monitoring and evaluating CDI and coding quality in relationship to best practices, while completing project-related reviews and providing relevant feedback to peers, coding, CDI leadership and quality partners, as necessary.
• Coordinates data collection and analysis, in collaboration with quality teams, related to patient care activities, documentation opportunities, coding opportunities and clinical outcome performance gaps.
• Coordinates the development of working sessions of multi-disciplinary teams in goal setting and problem solving.
• Optimizes service line clinical documentation integrity programs, including related provider and multidisciplinary education content creation, delivery and evaluation of effectiveness.
• Leads multidisciplinary and multi-departmental CDI projects to achieve strategic goals and objectives.
• Partners with other CDI leads, IT and other technology partners to create and optimize documentation tools, process and strategies to reduce administrative burden on our providers, while maintaining high quality and integrity documentation.

Education Qualifications

• Bachelor’s degree in Nursing, Medicine, Health Information Management or similarly related field of study.
• At least two currently active:
• COC, CPC, or CCS certification
• Certified Data Management Professional (CDMP) certification, Certified Analytics Professional (CAP) certification, or similar
• CRCR or other revenue cycle certification
• Health Care Quality (HACP, CPHQ, HCQM) certification
• Case Management Certification (CCM) or clinical certification
• Physician Educator Certificate Program (PECP) certification, or other education certification

Experience Qualifications

• Five (5) years of progressively responsible and directly related inpatient clinical experience. At least 5 years of CDI, or provider education related work experience. Outcomes data reporting and analysis experience.
• ICU/ED and Academic Medical Center experience preferred.
• Case management, utilization review and/or direct provider interaction experience, preferred.
• Experience in public speaking, as well as educational content creation and delivery of formal multidisciplinary education, preferred.
• Experience with Vizient, Premier, Elixhauser and other risk adjustment methodologies, highly preferred.

Required Knowledge, Skills and Abilities

• Expertise in coding and CDI practices., maintaining expertise in Medicare/Medicaid rules and regulations, as well as current trends and developments.
• Knowledge of, but not limited to, current CMS coding guidelines and methodologies, MS-DRGs, APR-DRGs, HCCs; current version of CM/PCS and AMA CPT coding guidelines and conventions, staying abreast of CMS rules and regulations and incorporating those changes into daily practice.
• Extensive knowledge and experience in computer systems, reporting software and electronic medical record systems used in functional area.
• Demonstrated leadership ability, organizational savviness, and critical thinking skills.
• Ability to develop and maintain strong, collaborative and supportive working relationships with peers, physicians and other clinical professionals.
• Must have demonstrated interpersonal, verbal and written communication skills in dealing with multidisciplinary teams and variety of ongoing activities.
• Knowledge of project management processes and systems with the ability to lead teams and manage high-profile projects to produce results within schedule and budget.
• Knowledge of statistical analysis and reporting practices pertaining to quality improvement and program evaluation.
• Ability to work independently, creatively, and innovation-focused in high-volume, fast- paced, and highly political work environments.
• Ability to work independently in performing duties with minimal supervision with a high degree of self-motivation.
• Expertise in developing and delivering training and education to clinical, CDI and coding professionals regarding CDI practices, coding, and documentation requirements, as well as knowledge distribution to multidisciplinary teams.

Licenses and Certifications

• At least 1 currently active:
• CCDS - Cert Clinical Document Spec .
• CCDS-O or CDIP .
• Nursing\\RN - Registered Nurse - State Licensure And/Or Compact State Licensure preferred .

These principles apply to ALL employees:

SHC Commitment to Providing an Exceptional Patient & Family Experience

_Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford’s patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery.

You will do this by executing against our three experience pillars, from the patient and family’s perspective:_

• Know Me: Anticipate my needs and status to deliver effective care
• Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health
• Coordinate for Me: Own the complexity of my care through coordination

Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.

Base Pay Scale: Generally starting at $72.64 - $96.23 per hour

The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.