Steve Roper

About Steve Roper

As a remote Clinical Documentation Integrity Specialist since 2009, I bring over three decades of clinical expertise and a sharp analytical lens to the concurrent review of inpatient charts. My role centers on ensuring documentation accuracy, completeness, and compliance with regulatory and coding standards. I collaborate with the Utilization Management department to evaluate patient status, determining whether clinical criteria support inpatient admission or warrant reclassification to outpatient care. I work closely with the HIM/Coding team to assign precise ICD-10 codes for diagnoses, conditions, and procedures, supporting accurate reimbursement and data integrity. Leveraging Epic EMR, I analyze patient histories and documentation to uphold the highest standards of chart integrity, ensuring that clinical entries reflect the true acuity and complexity of care.I have a keen ability to identify obscure or easily overlooked documentation elements that may carry significant clinical or financial impact—details that others might miss but that can influence coding, quality metrics, or risk adjustment. Over the years, I’ve worked diligently with Hospital-Acquired Conditions (HACs) and Patient Safety Indicators (PSIs), applying deep knowledge of inclusion and exclusion criteria to ensure accurate reporting and mitigation of penalties. I am well-versed in mortality risk scoring methodologies and routinely conduct retrospective reviews to optimize Elixhauser risk scores, enhancing institutional performance metrics and outcomes.Prior to transitioning into documentation integrity, I spent 16 years at the bedside in high-acuity environments. From 1993 to 1997, I served as a NTSICU RN, followed by roles in ICU and Post-Op Coronary CCU from 1997 to 2004. From 2004 to 2009, I worked as an Emergency Department RN in a Level II Trauma Center, where rapid decision-making and comprehensive clinical assessment were essential. This extensive critical care background informs my ability to interpret complex clinical scenarios and ensure documentation accurately captures the scope of patient care.In summary, my years in CDI have equipped me with a vast and nuanced understanding of clinical documentation, coding, and quality metrics. I am seeking an opportunity to continue applying this expertise within an organization that values precision, insight, and the kind of deep institutional knowledge I bring to the table.

Experience

1. Clinical Documentation Improvement Manager

   Enloe Health

   Oct 2009 — Present · Chico, CA, US

Education

• Some School

  Bachelor of Science - BS, Registered Nursing/Registered Nurse

  1988 — 1992

• Yup

  BSN, Registered Nursing, Nursing Administration, Nursing Research and Clinical Nursing

• Mazama High School

  General

  1981 — 1985