CDIS: Elevate Medical Records & Coding Quality

Adventist Health; Los Angeles (CA); On-site; USD 85,000 - 110,000; Full time

Job summary

Adventist Health seeks a Clinical Documentation Specialist to review patient records for illness specificity, accuracy of clinician documentation, and coding requirements. You will ensure complete and compliant documentation of medical records and support DRG assignments.

This role works with physicians and coding staff to maintain data integrity, communicates findings, and adapts to regulatory changes through ongoing education and collaboration.

Qualifications

• Associates/Technical degree or equivalent; three years of clinical experience; two years in clinical documentation is required.
• CCDS or DIP certification is required; current licensed RN, medical provider, or equivalent is required.

Responsibilities

• Evaluates and assesses medical records for specificity and documentation accuracy; conducts coding and DRG assignment; records review activity.
• Formulates physician queries, follows up on incomplete queries, and updates DRG as supported by documentation.
• Reviews data integrity, communicates deficiencies to department leads, and ensures compliance with federal/state regulations.
• Keeps abreast of regulatory changes in documentation and coding; participates in ongoing education sessions.
• Acts as liaison between medical staff and coding department to ensure accurate clinical information.

Skills

Clinical documentation

Medical records analysis

DRG assignment

Physician queries

Education

Associate/Technical Degree

Bachelor's Degree

Tools

Tracking software

Job description

Adventist Health seeks a Clinical Documentation Specialist to review patient records for illness specificity, accuracy of clinician documentation, and coding requirements. You will ensure complete and compliant documentation of medical records and support DRG assignments.

This role works with physicians and coding staff to maintain data integrity, communicates findings, and adapts to regulatory changes through ongoing education and collaboration.