CDI Lead: Elevate Medical Documentation & Compliance

Adventist HealthCare; United States; On-site; USD 77,000 - 116,000; Full time

Benefits offered by this job

Work life balance

Free Employee parking

Medical, Prescription, Dental, Vision

Tuition Reimbursement

EAP support

Job summary

Adventist HealthCare is seeking an experienced Clinical Documentation Improvement Lead for our Support Center to strengthen documentation accuracy, coding compliance, and patient care quality.

The role focuses on reviewing medical records, coordinating with physicians and the HIM team, and leading education initiatives on ICD-10-CM/PCS, CPT coding, and CMS guidelines to support reimbursement and improve outcomes.

Qualifications

• MD/DO/FMGE/RN/Pharmacist/Doctor of Physical Therapy are required or related professional degrees.
• RHIA/RHIT or related clinical health degree is required.
• Minimum 5 years inpatient clinical experience.
• 2+ years in clinical documentation, coding, case management, utilization review, or acute-care clinical experience.
• Experience interpreting physician documentation, labs, imaging and clinical indicators.
• Experience with ICD-10-CM/PCS, DRGs, SOI/ROM or HCC is a plus.

Responsibilities

• Examine medical records to ensure documentation is accurate and reflective of clinical status.
• Detect inconsistencies or missing information and request clarifications as necessary.
• Verify documentation supports correct ICD-10-CM/PCS and CPT coding for proper reimbursement.
• Collaborate with coding/revenue cycle team and ensure regulatory alignment.
• Communicate with physicians and staff to share insights and education to improve documentation practices.
• Support denial prevention and assist documentation for medical necessity and clinical validation.
• Contribute to quality improvement initiatives related to MHACs, PPCs, PSIs, SOI/ROM and mortality.
• Maintain productivity and quality logs; provide data for program metrics.
• Provide case-specific education to providers and escalate trends as needed.
• Assist in audits by ensuring proper documentation.

Education

MD/DO/FMGE/RN/Pharmacist/Doctor of Physical Therapy

RHIA/RHIT/related degree

Lean Six Sigma Green belt

CCDS/CDIP or equivalent

CDEI/CCS or equivalent

Job description

Adventist HealthCare is seeking an experienced Clinical Documentation Improvement Lead for our Support Center to strengthen documentation accuracy, coding compliance, and patient care quality.

The role focuses on reviewing medical records, coordinating with physicians and the HIM team, and leading education initiatives on ICD-10-CM/PCS, CPT coding, and CMS guidelines to support reimbursement and improve outcomes.