Entry-Level Clinical Documentation CDI Specialist

Stanford Health Care; United States; Remote; USD 160,033,000 - 212,040,000; Full time

Job summary

Stanford Health Care is seeking an entry-level Relief Clinical Documentation Integrity Specialist I to review and improve clinical documentation for accurate severity of illness, mortality risk, and care complexity.

You will learn to initiate reviews within 24–48 hours of admission, query physicians, and partner with inpatient coding teams to ensure precise DRG assignments while supporting CDI initiatives.

Qualifications

• Bachelor’s degree required in nursing, health information management, or related field.
• Entry-level to trainee CDI role with basic clinical, coding knowledge and ability to learn.
• Familiarity with documentation and coding guidelines helpful.

Responsibilities

• Review clinical documentation to improve accuracy of severity, mortality risk and care complexity.
• Initiate medical record reviews within 24–48 hours of admission and monitor records accordingly.
• Collaborate with inpatient coding staff to determine DRG and ensure high specificity of codes.
• Educate providers on documentation and coding concepts and query processes.
• Support CDI service line initiatives and provider engagement to improve outcomes.

Skills

Analytical thinking

Problem solving

Communication

Team collaboration

Self-motivation

Time management

Education

Bachelor’s degree in Nursing or Health Information Management or equivalent

Tools

3M Encoder

Epic EHR

MS Office

Job description

Stanford Health Care is seeking an entry-level Relief Clinical Documentation Integrity Specialist I to review and improve clinical documentation for accurate severity of illness, mortality risk, and care complexity.

You will learn to initiate reviews within 24–48 hours of admission, query physicians, and partner with inpatient coding teams to ensure precise DRG assignments while supporting CDI initiatives.