Overview Performs inpatient chart review to determine appropriate DRG assignment and assures appropriate documentation in the chart to support clinical care provided, including severity of illness and risk of mortality which impacts Case Mix Index and mortality ratings. Coordinates with physicians, nurses, ancillary staff, and the coders in Health Information Management to identify and record principal and secondary diagnoses, principal procedures, and assign the working DRG. Performs second level review of specific DRGs as assigned. Presents education related to CDI topics to peers and providers we needed or requested. Reviews DRG denials and provides information to the denials team related to appealing the encounter Qualifications Certifications: Registered Health Information Administrator (RHIA) - American Health Information Management Association (AHIMA)American Health Information Management Association (AHIMA); Licensed Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)Illinois Department of Financial and Professional Regulation (IDFPR), Education: Associate's Degree: Related Field, Work Experience: Clinical bedside; CDI Responsibilities Conducts the initial concurrent review process for all selected admissions. Clarifies documentation in the medical record as appropriate through communication with the physicians, nurses, and ancillary staff. Assures documentation in chart represents a true clinical picture of the patient diagnoses and supports care that was given and DRG assigned. Documents findings within Carle CDI software and updates software as required to reflect status of the encounter and any follow up. Coordinates with the physicians, nurses, ancillary hospital staff, and Health Information Management Department's coding staff to identify and record principal and secondary diagnoses, principal procedures, and assign the working DRG. Follows query process and escalates as necessary. Conducts education related to CDI topics to peers and providers as needed or requested. Performs second level review on selected inpatient encounters. Reviews denials for accurate and complete documentation and develops appeal letter when needed. Attends mandatory and regular education sessions as needed. Follows appropriate workflow in EPIC and CDI software and notifies one up leader of any issues. May serve as an "expert" and participate in testing for upgrades as needed. About Us Find it here. Discover the job, the career, the purpose you were meant for. At Carle Health, we're committed to fostering a workplace where every team member feels valued, respected and empowered, where passion and purpose come together to positively impact the lives of our patients and our communities. Find it all at Carle Health. Our nearly 17,000 team members and providers work together to support patient care across central and southeastern Illinois. We’ve grown to include eight, award-winning hospitals and a multispecialty provider group with more than 1,500 doctors and advanced practice providers. We’re developing the next generation of providers and healthcare professionals through Carle Illinois College of Medicine, the world’s first engineering-based medical school, and Methodist College. Carle BroMenn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet® designations, the nation’s highest honor for nursing care. We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health. We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information: human.resources@carle.com. Compensation and Benefits The compensation range for this position is $34.31per hour - $59.01per hour. This represents a good faith minimum and maximum range for the role at the time of posting by Carle Health. The actual compensation offered a candidate will be dependent on a variety of factors including, but not limited to, the candidate’s experience, qualifications, location, training, licenses, shifts worked and compensation model. Carle Health offers a comprehensive benefits package for team members and providers. To learn more visit careers.carlehealth.org/benefits.

• Lead a team of up to 8 CDSs • Ongoing audits and feedback for CDSs in pod • Routine 1:1s • Point person for suspecting questions from CDSs within their pod • Conduct bi-weekly pod meetings • New CDS onboarding • Quarterly Slide Training for CDS Onboarding will be shared between Supervisors with rotation based on new hire start date • Documentation Reviews and Suspecting Chart reviews for high priority / new providers / first WRVs / targeted lists • Attendance at targeted Clinical Documentation Reviews as needed • Partnership with Population Health Directors on general chart review support and strategies for region • Medical Records Access and review HIE/EMRs to identify potential suspects based on test results, imaging reports, etc. • Identify need for medical records requests from patient information, including payer data • Be an expert in tracking down and leveraging external resources, such as hospital records, Blue Button, and payer data, to support retrospective and prospective accurate documentation • Identify regional trends and training opportunities to support clinical documentation accuracy improvement • Identify and analyze opportunities for improving patient quality outcomes and cost of care • Analyze chronic condition prevalence based on patient demographics and identify opportunities for interventions • Structure initiatives to drive improvement in quality and risk adjustment documentation results • Monitor clinical documentation efforts • Develop predictive analytics insights • Other duties, as assigned

1.0 FTE Full time Day - 08 Hour R2654892 Remote USA 109012014 Shared Svcs Rev Cycle CDI TV Finance & Revenue Cycle 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 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 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. Entry-level professional with limited or no prior experience; learns to use professional concepts to resolve problems of limited scope and complexity; works on developmental assignments that are initially routine in nature, requiring limited judgment and decision making. ​Performs the more routine CDI work and in a learning capacity, assists in the technical review of various types of medical records within expanding scope of clinical specialty and some exposure to additional complexity, as well as exposure to other projects. ​Requires basic clinical, coding and/or CDI knowledge and understanding of the theories, concepts, principles and practices of medical record documentation and/or data analysis. ​Learns to apply professional principles, theories, and concepts through work assignments. Works on problems of limited scope; routine in nature. Follows standard practices and procedures in analyzing situations or data from which answers can be readily obtained. ​Close monitoring and partnership with preceptors/more experienced Clinical Documentation Integrity Specialists. ​Works under close supervision. Assignments are designed to provide training and practical experience that develops the incumbent's ability to apply CDI and coding principles, methodologies, and procedures. Decisions are limited to specific, task-related activities. ​Requires the manager's, Lead's or preceptor's review of the work performed, while in progress and at its completion, for accuracy, completeness, and conformance with detailed instructions. Work is primarily with existing, stable processes and procedures. As the employee's skill level progresses, close supervision is relaxed. Supervised and limited client interaction. As the employee's skill level progresses, supervision of limited interaction is relaxed.​ Locations Stanford Health Care 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 by improving the quality of the physician’s clinical documentation. - Initiates medical record review within 24 to 48 hours of admission. Monitors, systematically, the targeted medical records within at least 48 hours unless otherwise indicated) to determine compliance to established documentation standards. Conducts follow-up reviews to ensure points of clarification have been addressed/documented in the medical record. - Utilizes Hospital coding code set, policies and procedures, Federal and State coding reimbursement guidelines, and application of the Coding Clinic Guidelines to assign working DRG, reviewing patient records throughout hospitalization that have been identified as focus DRG by regulatory agencies or the facility to ensure the codes are reported at the highest specificity. - Partners with the Inpatient coding staff to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, risk of mortality and quality outcomes. - Advises and counsels clinical providers in assigned areas in clinical documentation and coding concepts, query procedures and processes. - Responsible for units and/or service lines assigned by manager. - Maintains liaison with department or service line clinical providers in documentation Integrity strategies, opportunities and specific clarification requests. - Suggests improvements to enhance documentation Integrity or clinical provider documentation process. - Documentation Integrity Strategies and Provider Partnership: - Contributes to provider engagement, relationship establishment and maintenance related to CDI and documentation Integrity efforts, with all providers through the query process. - Addresses abnormal ancillary test findings when they occur and query physicians on a current basis to include face-to-face interactions regarding the impact on patient care and DRG assignment. - Initiates physician interaction when ambiguous, missing or conflicting information is in the medical record, through the physician query process and/or participation in rounding with the physicians by requesting additional documentation for correct coding and compliance necessary for accurate reflection of CMI, LOS, and optimal resource utilization. - Assists CDI service line teams and leadership in the ongoing evaluation of clinical documentation and potential improvement initiatives. - Documentation Performance, Reporting and Enhancements: - Performs ongoing documentation analysis for assigned units and/or service lines and submits documentation clarifications or queries to mitigate gaps or inconsistency in documentation, thus ensuring the accuracy of code capture and resulting outcomes. - Assists other peers and leadership understanding variance and other documentation and CDI related barriers. - Develops or recommends improvements/enhancements to documentation tools, provider engagement and/or processes related to documentation and related outcomes, as needed. - Assists in reconciling query and non-query impact within the CDI data entry systems. - Project management regarding clinical documentation initiatives and analysis of potential scope expansion or opportunity identification and resolution Education Qualifications - Bachelor’s degree in Nursing, Medicine, Health Information Management or similarly related field of study or equivalent combination of education and experience Experience Qualifications - ​​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 - Analysis & Problem Solving: - 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. - Demonstrates knowledge of and application of AHIMA and ACDIS Ethical Standards. - Knowledge of, but not limited to, current CMS coding guidelines and methodologies, MS-DRGs, APR-DRGs, HCCs; ICD-10-CM/PCS and AMA CPT coding guidelines and conventions. - Demonstrates adaptability and self-motivation by staying abreast of CMS rules and regulations and incorporating those changes into daily practice. - Ability and willingness to seek out and accept change. - Demonstrates judgment and independent decision making. - Ability to work independently in performing duties with minimal supervision with a high degree of self-motivation. - Knowledge of the principles and practices of financial analysis and cost accounting. - Knowledge of local, state, and federal regulatory requirements related to the functional area. - Ability to analyze and develop solutions to problems. - Ability to analyze information, reach valid conclusions, and make sound recommendations. - Ability to apply judgment and make informed decisions. - Ability to communicate complex concepts in simple form to non-CDI or Revenue Cycle experts to understand the appropriate use and limits of the information provided. - Ability to manage, organize, prioritize, multi-task, adapt to priorities, and meet deadlines. - Ability to learn new solutions, functionality, and technology. - Ability to effectively and autonomously manage projects involving multidisciplinary teams and work flows. - Reporting & Data Management: - Ability to provide concise reports of activities and results. - Ability to work with clinical manager and physicians to make clinical documentation improvements e.g. change clinical documentation processes. - Ability to successfully navigate multiple projects and responsibilities - Ability to track activities and communications across multiple physician services and forums. Able to work on multiple tasks; independent in prioritizing work. - Ability to create, deliver and manage educational content related to clinical documentation Integrity. - Proficient with Microsoft Applications including word processing, spreadsheets, and presentation software. - Knowledge of analytical research procedures and methods. - Ability to assess reporting systems and develop process/procedural improvements. - Ability to capture and understand data from available sources and turn it into useful information for decision-making. - Ability to assess data and reporting tools or make recommendations regarding their improvement or enhancement. - Ability to perform tests, data auditing, and implementation of CDI and Coding software or documentation processes. - Customer Support / Interactions with Others: - Ability to develop and maintain supportive, collaborative relationships with Physicians and other clinical professionals. - Demonstrates interpersonal, verbal and written communication skills in dealing with inter and intradepartmental activities. - Collaborates with others as a "team player", including interdepartmental team work; contributes to effective team action. Able to work with a variety of individuals and groups within the organization. - Mastery in verbal and written English communication. - Ability to communicate effectively, orally and in writing, including summarizing data and presenting results both one-on-one and in group settings. - Ability to guide and educate SHC staff on procedures and processes. - Ability to support the education and training of end-users. - Ability to provide advice and counsel clients/customers on a broad range of CDI, coding, outcomes and documentation matters regarding effectiveness, compliance and efficiency. - Technology - Beginning to intermediate MS Office Suite applications. - Some exposure to an encoder and/or electronic health record systems. - Intermediate to advanced MS Office Suite applications. - Exposure to or experience with 3M encoder and/or Epic electronic health record systems. Licenses and Certifications - 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 $55.85 - $74.00 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.

Your future role at a glance Location: Remote Facility: Ascension Saint Thomas Department: Clinical Documentation Schedule: Full time | Days Salary: $75,535 - $105,292 per year Life at Ascension: Where purpose meets opportunity Ascension is a leading nonprofit Catholic health system with a culture and associate experience grounded in service, growth, care and connection. We empower our 99,000+ associates to bring their skills and expertise every day to reimagining healthcare, together. Recognized as one of the Best 150+ Places to Work in Healthcare and a Military-Friendly Gold Employer, you’ll find an inclusive and supportive environment where your contributions truly matter. Benefits that help you thrive - Comprehensive health coverage: medical, dental, vision, prescription coverage and HSA/FSA options - Financial security & retirement: employer-matched 403(b), planning and hardship resources, disability and life insurance - Time to recharge: pro-rated paid time off (PTO) and holidays - Career growth: Ascension-paid tuition (Vocare), reimbursement, ongoing professional development and online learning - Emotional well-being: Employee Assistance Program, counseling and peer support, spiritual care and stress management resources - Family support: parental leave, adoption assistance and family benefits - Other benefits: optional legal and pet insurance, transportation savings and more Benefit options and eligibility vary by position, scheduled hours and location. Benefits are subject to change at any time. Your recruiter will provide the most up-to-date details during the hiring process. How you’ll make an impact in this role - Translate Clinical Care into Accurate Data: Perform comprehensive admission reviews to assign working Diagnosis Related Groups (DRGs), ensuring all clinical indicators are captured within our CDI database. - Act as a Peer Consultant: Build and maintain collaborative, high-trust relationships with physicians and mid-level providers. You’ll engage in meaningful dialogue to capture the "why" behind the care, ensuring the medical record is as detailed and accurate as possible. - Drive Real-Time Resolution: Work side-by-side with the healthcare team to resolve documentation queries and discrepancies before patient discharge, ensuring the chart is a true reflection of the services provided. - Uphold Integrity & Validity: Maintain meticulous records of your review activities. Your oversight ensures that our CDI efforts produce valid reports and measurable improvements in patient data quality. What minimum requirements you’ll need Licensure / Certification / Registration: - One or more of the following required: - Certified Coding Specialist (CCS) credentialed from the American Health Information Management Association (AHIMA) obtained within 6 Months (180 days) of hire date or job transfer date. - Reg Health Info Admnstr credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date. - Reg Health Info Tech credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date. - Certified Professional Coder (CPC) credentialed from the American Academy of Professional Coders (AAPC) obtained within 6 Months (180 days) of hire date or job transfer date. - Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date. - Licensed Registered Nurse credentialed from the Tennessee Board of Nursing or current home state license for multi-state license recognition "Compact State" obtained prior to hire date or job transfer date. Education: - High School diploma equivalency with 2 years of cumulative experience OR Associate's degree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required. Equal employment opportunity employer Ascension provides Equal Employment Opportunities (EEO) to all associates and applicants for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy, childbirth, and related medical conditions, lactation, breastfeeding, national origin, citizenship, age, disability, genetic information, veteran status, marital status, all as defined by applicable law, and any other legally protected status or characteristic in accordance with applicable federal, state and local laws. For further information, view the EEO Know Your Rights (English) poster or EEO Know Your Rights (Spanish) poster. Fraud prevention notice Prospective applicants should be vigilant against fraudulent job offers and interview requests. Scammers may use sophisticated tactics to impersonate Ascension employees. To ensure your safety, please remember: Ascension will never ask for payment or to provide banking or financial information as part of the job application or hiring process. Our legitimate email communications will always come from an @ascension.org email address; do not trust other domains, and an official offer will only be extended to candidates who have completed a job application through our authorized applicant tracking system. E-Verify statement Employer participates in the Electronic Employment Verification Program. Please click here for more information.