Remote CDI Specialist I: Elevate Patient Documentation

Stanford Health Care; Sacramento (CA); On-site; USD 77,000 - 102,000; Part time

Job summary

Stanford Health Care is seeking an entry level Relief Clinical Documentation Integrity Specialist I. The role focuses on reviewing inpatient and outpatient records to improve clinical documentation, supporting accurate DRG assignment, severity of illness and mortality risk assessments.

Training is provided, with supervision and developmental opportunities across CDI and coding processes. As a trainee, you will engage with physicians to clarify documentation, participate in rounds, and assist in

Qualifications

• Bachelor’s degree in Nursing, Medicine, Health Information Management or equivalent.
• Entry-level CDI trainee with basic clinical, coding knowledge and understanding of documentation principles.
• Familiarity with CMS coding guidelines, ICD-10-CM/PCS and related documentation practices.

Responsibilities

• Review clinical documentation to accurately reflect illness severity, mortality risk and care complexity.
• Initiate medical record review within 24–48 hours of admission and monitor records for compliance with standards.
• Query providers to clarify documentation and ensure accurate coding for DRG assignment and outcomes.
• Collaborate with inpatient coding staff to validate diagnostic and procedural data and DRG determinations.
• Provide education to clinicians on documentation and coding concepts and improvements.

Skills

Clinical documentation

Medical coding

CMS guidelines

Communication

Education

Bachelor’s degree in Nursing, Medicine, Health Information Management

Tools

MS Office

3M encoder

Epic EHR

Job description

Stanford Health Care is seeking an entry level Relief Clinical Documentation Integrity Specialist I. The role focuses on reviewing inpatient and outpatient records to improve clinical documentation, supporting accurate DRG assignment, severity of illness and mortality risk assessments.

Training is provided, with supervision and developmental opportunities across CDI and coding processes. As a trainee, you will engage with physicians to clarify documentation, participate in rounds, and assist in