Clinical Documentation Improvement Lead, Day Shift, Patient Clinical Documentation

Adventist HealthCare; Gaithersburg (MD); On-site; USD 77,000 - 116,000; Full time

Benefits offered by this job

Medical coverage

Paid time off

Retirement plan with match

Job summary

Adventist HealthCare is seeking an experienced Clinical Documentation Improvement Lead for the Support Center to ensure accurate, complete documentation reflecting patient status. You will work with physicians and clinical staff to educate and improve documentation practices, support medical necessity validation, and participate in audits and quality initiatives.

The role requires strong inpatient CDI experience, CCDS/CDIP or equivalent, and relevant certifications, with a focus on CMS

Qualifications

• MD/DO/RN/Pharmacist/Doctor of Physical Therapy degree required.
• RHIA/RHIT or related clinical degree, or equivalent, preferred or within 90 days.
• Minimum of 5 years inpatient clinical experience.
• 2+ years in clinical documentation, coding, case management, utilization review, or acute-care clinical experience.
• CCDS/CDIP or equivalent certification required or within 90 days; Lean Six Sigma Green Belt preferred.

Responsibilities

• Examine medical records to ensure documentation reflects patient’s clinical status.
• Detect inconsistencies, ambiguities, or missing information and request provider clarifications as necessary.
• Verify that documentation supports correct ICD-10-CM/PCS and CPT coding for proper reimbursement; collaborate with coding/revenue cycle teams.
• Communicate with physicians and clinical staff to share insights, trends, and education to improve documentation practices.
• Support denial prevention and contribute to documentation for medical necessity and clinical validation; participate in audits and education.

Job description

Support CenterIf you are a current Adventist HealthCare employee, please click this link to apply through your Workday account.Adventist HealthCare seeks to hire an experienced Clinical Documentation Improvement Lead for our Support Center who will embrace our mission to extend God’s care through the ministry of physical, mental, and spiritual healing.As a Clinical Documentation Improvement Lead, you will:• Examine medical records to ensure documentation is accurate, complete, and reflective of the patient’s clinical status.• Detect inconsistencies, ambiguities, or missing information in the medical record that may impact coding, compliance, or patient care and request provider clarifications as necessary.• Verify that clinical documentation supports correct ICD-10-CM/PCS and CPT coding for proper reimbursement and collaborates with the coding/revenue cycle team.• Ensure that documentation and provider queries align with regulatory standards, including CMS guidelines and organizational policies. • Communicates and establishes relationships with physicians and clinical staff to share insights, trends and education to improve documentation practices.• Support denial prevention and proactively learn and support documentation for medical necessity, clinical validation and partner with physician advisor/HIM/Coding as needed• Contributes to organizational quality improvement initiatives by ensuring robust and accurate documentation related to MHACs, PPCs, PSIs, SOI/ROM and mortality.• Maintain individual productivity and quality logs; contributes data for program metrics (query response rate, agreement rate, chart review volume).• Provide case specific education to the providers/clinical staff based on identified gaps escalating broader trends/needs to Lead.• Assist in internal and external audits by ensuring proper documentation and addressing identified issues.• Maintains and enhances current medical, coding, and CDI knowledge via participating in continuing education offerings.Qualifications include:• Doctor of Medicine (MD), Doctor of Osteopathy (DO), Foreign Medical Graduate (FMG), Registered Nurse (RN), Pharmacist, Doctor of Physical Therapy• RHIA, RHIT, or related clinical/allied health degree• Minimum of 5 years inpatient clinical experience• 2+ years of clinical documentation, coding, case management, utilization review, or acute-care clinical experience• Experience interpreting physician documentation, lab results, imaging, and clinical indicators.• Experience with ICD-10-CM/PCS, DRGs, SOI/ROM or HCC is a plus• Lean Six Sigma Green belt preferred• Solventum360 preferred• CCDS (Certified Clinical Documentation Specialist), CDIP (Clinical Documentation Improvement Practitioner) or equivalent required or within 90 days• Other certifications preferred:• Certified Documentation Expert Inpatient (CDEI)• Certified Coding Specialist (CCS)Work Schedule:Employment Type: Full-timeHours per Week: 40 hours/weekTypical Daily Schedule: 8 am-4 pm Monday through FridayShift Type: Day ShiftHoliday Requirements: Follow the company holiday calendarPay Range:$77,313.60 - $115,980.80If the salary range is listed as $0 or if the position is Per Diem (with a fixed rate), salary discussions will take place during the screening process.Under the Fair Labor Standards Act (FLSA), this position is classified as:United States of America (Exempt)At Adventist HealthCare our job is to care for you.We do this by offering:Work life balance through nonrotating shiftsRecognition and rewards for professional expertiseFree Employee parkingMedical, Prescription, Dental, and Vision coverage for employees and their eligible dependents effective on your date of hireEmployer-paid Short & Long-Term Disability, Basic Life Insurance and AD&D, (short-term disability buy-up available)Paid Time OffEmployer retirement contribution and match after 1-year of eligible employment with a 3-year vesting periodVoluntary benefits include flexible spending accounts, legal plans, and life, pet, auto, home, long term care, and critical illness & accident insuranceSubsidized childcare at participating childcare centersTuition ReimbursementEmployee Assistance Program (EAP) supportAs a faith-based organization, with over a century of caring for the communities in the Maryland area, Adventist HealthCare has earned a reputation for high-quality, compassionate care. Adventist HealthCare was the first and is the largest healthcare provider in Montgomery County.If you want to make a difference in someone’s life every day, consider a position with a team of professionals who are doing just that, making a difference.Join the Adventist HealthCare team today, apply now to be considered!COVID-19 VaccinationAdventist HealthCare strongly recommends all applicants to be fully vaccinated for COVID-19 before commencing employment. Applicants may be required to furnish proof of vaccination.Tobacco and Drug StatementTobacco use is a well-recognized preventable cause of death in the United States and an important public health issue. In order to promote and maintain a healthy work environment, Adventist HealthCare will not hire applicants for employment who either state that they are nicotine users or who test positive for nicotine and drug use.While some jurisdictions, including Maryland, permit the use of marijuana for medical purposes, marijuana continues to be classified as an illegal drug under the federal Controlled Substances Act. As a result, medical marijuana use will not be accepted as a valid explanation for a positive drug test result.Adventist HealthCare will withdraw offers of employment to applicants who test positive for Cotinine (nicotine) and marijuana. Those testing positive are given the opportunity to re-apply in 90 days, if they can truthfully attest that they have not used any nicotine products in the past ninety (90) days and successfully pass follow-up testing. (\"Nicotine products\" include, but are not limited to: cigarettes, cigars, pipes, chewing tobacco, e-cigarettes, vaping products, hookah, and nicotine replacement products (e.g., nicotine gum, nicotine patches, nicotine lozenges, etc.).Equal Employment OpportunityAdventist HealthCare is an Equal Opportunity/Affirmative Action Employer. We are committed to attracting, engaging, and developing the best people to cultivate our mission-centric culture. Our goal is to have a welcoming, equitable, and safe place to work and grow for all employees, no matter their background. AHC does not discriminate in employment opportunities or practices on the basis of race, ethnicity, color, religion, sex, national origin, age, disability, sexual orientation, gender identity, pregnancy and related medical conditions, protected veteran status, or any other characteristic protected by law.Adventist HealthCare will make reasonable accommodations for applicants with disabilities, in accordance with applicable law. Adventist HealthCare is a religious organization as defined under applicable law; however, it will endeavor to provide reasonable accommodations for applicants’ religious beliefs.Applicants who wish to request accommodations for disabilities or religious belief should contact the Support Center HR Office.