Stanford Health Care
Clinical Documentation Integrity Lead - Service Line (Remote)
Stanford Health Care, Sacramento, California, United States, 95828
Overview
Clinical Documentation Integrity (CDI) Service Line Outcomes Lead
is responsible for partnering with service line and 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 and facilitate targeted education opportunities, and strengthen overall buy-in and engagement. Locations
Stanford Health Care What You Will Do Responsibilities 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. Perform CDI targeted audits and analysis of the findings related to documentation and coding to build physician education, identify areas of opportunity, and facilitate short- and long-term resolutions. Serve as a subject matter expert on interpretation and application of CDI practices, coding rules and regulations, and conduct risk assessments of potential and detected compliance deficiencies, as well as documentation opportunities within the service lines assigned. Assist in monitoring and evaluating CDI and coding quality in relation to best practices, while completing project-related reviews and providing relevant feedback to peers, coding, CDI leadership and quality partners, as necessary. Coordinate data collection and analysis, in collaboration with quality teams, related to patient care activities, documentation opportunities, coding opportunities and clinical outcome performance gaps. Coordinate the development of working sessions of multi-disciplinary teams in goal setting and problem solving. Optimize service line clinical documentation integrity programs, including related provider and multidisciplinary education content creation, delivery and evaluation of effectiveness. Lead multidisciplinary and multi-departmental CDI projects to achieve strategic goals and objectives. Partner with other CDI leads, IT and other technology partners to create and optimize documentation tools, process and strategies to reduce administrative burden on providers, while maintaining high quality and integrity documentation.
Education Qualifications
Bachelors degree in Nursing, Medicine, Health Information Management or similarly related field of study. At least two currently active: COC, CPC, or CCS certification CDMP certification, 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 CMS coding guidelines and methodologies, MS-DRGs, APR-DRGs, HCCs; current 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 Specialist; CCDS-O or CDIP; Nursing RN licensure preferred.
Equal Opportunity and Commitment
Equal Opportunity Employer
Stanford Health Care values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including employment. SHC does not discriminate 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. People of all genders, races, ethnicities, disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after individualized assessment of the conviction and job requirements. Base Pay Scale : Generally starting at $68.46 - $90.70 per hour. The final salary will be set based on factors including internal equity, experience, education, and training. Other Details
Seniority level: Mid-Senior level Employment type: Full-time Job function: Health Care Provider Industries: Hospitals and Health Care
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Clinical Documentation Integrity (CDI) Service Line Outcomes Lead
is responsible for partnering with service line and 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 and facilitate targeted education opportunities, and strengthen overall buy-in and engagement. Locations
Stanford Health Care What You Will Do Responsibilities 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. Perform CDI targeted audits and analysis of the findings related to documentation and coding to build physician education, identify areas of opportunity, and facilitate short- and long-term resolutions. Serve as a subject matter expert on interpretation and application of CDI practices, coding rules and regulations, and conduct risk assessments of potential and detected compliance deficiencies, as well as documentation opportunities within the service lines assigned. Assist in monitoring and evaluating CDI and coding quality in relation to best practices, while completing project-related reviews and providing relevant feedback to peers, coding, CDI leadership and quality partners, as necessary. Coordinate data collection and analysis, in collaboration with quality teams, related to patient care activities, documentation opportunities, coding opportunities and clinical outcome performance gaps. Coordinate the development of working sessions of multi-disciplinary teams in goal setting and problem solving. Optimize service line clinical documentation integrity programs, including related provider and multidisciplinary education content creation, delivery and evaluation of effectiveness. Lead multidisciplinary and multi-departmental CDI projects to achieve strategic goals and objectives. Partner with other CDI leads, IT and other technology partners to create and optimize documentation tools, process and strategies to reduce administrative burden on providers, while maintaining high quality and integrity documentation.
Education Qualifications
Bachelors degree in Nursing, Medicine, Health Information Management or similarly related field of study. At least two currently active: COC, CPC, or CCS certification CDMP certification, 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 CMS coding guidelines and methodologies, MS-DRGs, APR-DRGs, HCCs; current 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 Specialist; CCDS-O or CDIP; Nursing RN licensure preferred.
Equal Opportunity and Commitment
Equal Opportunity Employer
Stanford Health Care values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including employment. SHC does not discriminate 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. People of all genders, races, ethnicities, disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after individualized assessment of the conviction and job requirements. Base Pay Scale : Generally starting at $68.46 - $90.70 per hour. The final salary will be set based on factors including internal equity, experience, education, and training. Other Details
Seniority level: Mid-Senior level Employment type: Full-time Job function: Health Care Provider Industries: Hospitals and Health Care
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