Clinical Documentation Improvement Specialist, Day Shift, Clinical Documentation

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

Benefits offered by this job

Free Employee parking

Medical, Prescription, Dental, and Vis

Employer retirement contribution

Tuition Reimbursement

EAP support

Job summary

Adventist HealthCare is seeking a Clinical Documentation Specialist to ensure accurate and compliant medical record documentation across inpatient settings. The role involves analyzing records for accuracy, identifying missing data, and coordinating with physicians to obtain clarifications.

You will verify ICD-10-CM/PCS and CPT coding for proper reimbursement, align with CMS guidelines, and support education on documentation best practices.

Qualifications

• MD/DO/FM G, RN, Pharmacist or PT degrees or equivalent.
• RHIA or RHIT or related clinical degree preferred or within 90 days of start.
• Minimum 5 years inpatient clinical experience.
• 2+ years in clinical documentation, coding, case management, utilization review, or acute-care experience.
• Experience with ICD-10-CM/PCS, DRGs, SOI/ROM or HCC is a plus.

Responsibilities

• Examine medical records to ensure documentation is accurate, complete and reflective of patient status.
• Detect inconsistencies or missing information and request clarifications from providers.
• Verify documentation supports correct ICD-10-CM/PCS and CPT coding for proper reimbursement.
• Ensure alignment with CMS guidelines and organizational policies.
• Communicate with physicians to share insights and educate on documentation improvements.
• Contribute to quality improvement by robust documentation related to MHACs, PPCs, PSIs, SOI/ROM and mortality.
• Track and report metrics related to documentation quality.

Skills

Clinical documentation

ICD-10-CM/PCS

CPT coding

Query management

Regulatory compliance

Education

MD/DO/FM G/RN/Pharmacist/PT

Job description

Remote

Adventist HealthCare seeks to hire a Clinical Documentation Specialist who will embrace our mission to extend God’s care through the ministry of physical, mental and spiritual healing.

As a Clinical Documentation Specialist 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.
• Contributes to organizational quality improvement initiates by ensuring robust and accurate documentation related to MHACs, PPCs, PSIs, SOI/ROM and mortality.
• Track and report on metrics related to documentation quality, such as query response rates or documentation accuracy.
• Provide guidance and education on documentation best practices and standards to physician and clinical staff to support ongoing improvement.
• 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.

Education and Experience:

• 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-time
• Hours per Week: 40 hours
• Typical Daily Schedule: Monday through Friday
• Shift Type: Day Shift
• Weekend Requirements: No Weekends

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)

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

As 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.

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.