Clinical Documentation Improvement Lead, Day Shift, Patient Clinical Documentation

Adventist HealthCare; United States; Sur place; USD 77 000 - 116 000; Plein temps

Avantages offerts par ce poste

Work life balance

Free Employee parking

Medical, Prescription, Dental, Vision

Tuition Reimbursement

EAP support

Résumé du poste

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.

Responsabilités

• 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.

Formation

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

Description du poste

Support Center

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)

Employment Details

Employment Type: Full-time

Hours per Week: 40 hours/week

Typical Daily Schedule: 8 am-4 pm Monday through Friday

Shift Type: Day Shift

Holiday Requirements: Follow the company holiday calendar

Pay Range: $77,313.60 - $115,980.80

If 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)

Benefits and Perks

At Adventist HealthCare our job is to care for you. We do this by offering:

• Work life balance through nonrotating shifts
• Recognition and rewards for professional expertise
• Free Employee parking
• Medical, Prescription, Dental, and Vision coverage for employees and their eligible dependents effective on your date of hire
• Employer-paid Short & Long-Term Disability, Basic Life Insurance and AD&D, (short-term disability buy-up available)
• Paid Time Off
• Employer retirement contribution and match after 1-year of eligible employment with a 3-year vesting period
• Voluntary benefits include flexible spending accounts, legal plans, and life, pet, auto, home, long term care, and critical illness & accident insurance
• Subsidized childcare at participating childcare centers
• Tuition Reimbursement
• Employee Assistance Program (EAP) support

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.

COVID-19 Vaccination

Adventist 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 Statement

Tobacco 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 Opportunity

Adventist 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.

Our Mission

We extend God's care through the ministry of physical, mental and spiritual healing. Adventist HealthCare, based in Gaithersburg, MD., is a faith-based, not-for-profit organization of dedicated professionals who work together each day to improve the health and well-being of people and communities through a ministry of physical, mental and spiritual healing. Our comprehensive approach to caring for our community includes three acute-care hospitals – Shady Grove Medical Center, White Oak Medical Center and Fort Washington Medical Center – as well as two Physical Rehabilitation hospitals, Outpatient centers, Imaging Centers, Urgent Cares, Home Care Services, Employer Health Programs and Physician Networks. We are nationally recognized and honored especially for our Cardiac, OB, Cancer, Stroke, Orthopedic, Rehabilitation and Mental Health services. Consider joining our team of over 6,000 employees and become part of one of the longest serving healthcare systems in the Washington, D.C., area that has a long-standing tradition as the largest provider of charity care and community benefit in Montgomery County.

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