[Hiring] Clinical Documentation Integrity Specialist I @Stanford Health Care

Role Description

The Relief Clinical Documentation Integrity Specialist I uses clinical and coding knowledge for conducting clinically based concurrent and retrospective reviews of inpatient and/or outpatient medical records to evaluate the clinical documentation of clinical services by identifying opportunities for improving the quality of medical record documentation. Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate communication, severity of illness, expected risk of mortality, and complexity of care of the patient.

A successful Relief Clinical Documentation Integrity Specialist I will be adept in clinical experience and knowledge, understanding documentation and coding guidelines, recognizing gaps and issues, as well as the impact of documentation and coding on the patients, the providers, the hospital and related outcomes.

This is an entry level, trainee and contributing level position. Responsibilities include:

• Performing routine CDI work and assisting in the technical review of various types of medical records.
• Learning to apply professional principles, theories, and concepts through work assignments.
• Working on problems of limited scope; routine in nature.
• Following standard practices and procedures in analyzing situations or data.
• Close monitoring and partnership with preceptors/more experienced Clinical Documentation Integrity Specialists.
• Working under close supervision.

What you will do

• Documentation and Coding Analysis:
  • Reviews clinical documentation to facilitate the accurate representation of the severity of illness, expected risk of mortality, and complexity of care.
  • Initiates medical record review within 24 to 48 hours of admission.
  • Monitors targeted medical records to determine compliance with established documentation standards.
  • Utilizes Hospital coding code set, policies and procedures, Federal and State coding reimbursement guidelines, and Coding Clinic Guidelines.
  • Partners with Inpatient coding staff to ensure accuracy of diagnostic and procedural data.
  • Advises and counsels clinical providers in assigned areas regarding clinical documentation and coding concepts.
  • Maintains liaison with department or service line clinical providers in documentation Integrity strategies.
  • Suggests improvements to enhance documentation Integrity or clinical provider documentation process.
• Documentation Integrity Strategies and Provider Partnership:
  • Contributes to provider engagement and relationship establishment related to CDI and documentation Integrity efforts.
  • Addresses abnormal ancillary test findings and queries physicians on a current basis.
  • Initiates physician interaction when ambiguous, missing or conflicting information is in the medical record.
  • Assists CDI service line teams and leadership in evaluating clinical documentation and potential improvement initiatives.
• Documentation Performance, Reporting and Enhancements:
  • Performs ongoing documentation analysis for assigned units and/or service lines.
  • Assists peers and leadership in understanding variance and other documentation-related barriers.
  • Develops or recommends improvements/enhancements to documentation tools and processes.
  • Assists in reconciling query and non-query impact within the CDI data entry systems.
  • Project management regarding clinical documentation initiatives.

Qualifications

• Bachelor’s degree in Nursing, Medicine, Health Information Management or similarly related field of study or equivalent combination of education and experience.

Requirements

• Five (5) 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.

Required Knowledge, Skills and Abilities

• Demonstrates ability to analyze problems and issues and understand the regulatory and reimbursement impact of those decisions.
• Demonstrates critical thinking skills, able to assess, evaluate, and teach.
• Demonstrates organization and analytical thinking skills.
• Knowledge of current CMS coding guidelines and methodologies.
• Ability to work independently with minimal supervision.
• Ability to communicate complex concepts in simple form.
• Ability to manage, organize, prioritize, multi-task, adapt to priorities, and meet deadlines.
• Proficient with Microsoft Applications including word processing, spreadsheets, and presentation software.

Licenses and Certifications

• RN - Registered Nurse - State Licensure And/Or Compact State Licensure preferred.

Benefits

• Base Pay Scale: Generally starting at $55.85 - $74.00 per hour.
• The salary of the finalist selected for this role will be set based on various factors.

Company Description

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 patients, families, and towards each other.