Clinical Documentation Improvement Specialist (Remote), Day Shift, Clinical Documentation

Adventist HealthCare; Buffalo (NY); Remote; USD 77,000 - 116,000; Full time

Benefits offered by this job

Work life balance

Employer retirement contribution and 3

Paid Time Off

Medical,Dental,Vision coverage

Job summary

Adventist HealthCare seeks a Clinical Documentation Specialist to extend God’s care through a ministry of healing. The role focuses on reviewing medical records to ensure accurate documentation reflecting patient status, and educating staff to improve quality and compliance.

Responsibilities include resolving documentation gaps, coordinating with the coding/revenue cycle teams, and supporting audits. The position emphasizes quality improvement and adherence to CMS guidelines, with a remote day

Qualifications

• MD/DO/FMGE/RN/Pharmacist/Physical Therapist required or equivalent.
• RHIA/RHIT or related clinical degree.
• Minimum 5 years inpatient clinical experience.
• 2+ years in clinical documentation, coding, case management or utilization review.
• Experience interpreting physician documentation and tests.
• ICD-10-CM/PCS, DRGs, SOI/ROM or HCC a plus.

Responsibilities

• Examine medical records for accuracy and completeness.
• Detect inconsistencies and request physician clarifications.
• Ensure documentation supports ICD-10-CM/PCS and CPT coding for reimbursement.
• Align documentation with CMS guidelines and policies.
• Educate physicians and clinicians to improve documentation practices.
• Track and report metrics on documentation quality.

Skills

Clinical documentation

Inpatient experience

Regulatory compliance

Physician communication

Education

MD/DO/FMGE/RN/Pharmacist/PT

RHIA/RHIT or related degree

Tools

Lean Six Sigma Green belt

Solventum360

CCDS

CDIP

Job description

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.

Responsibilities

• 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-Remote

Weekend Requirements: No Weekends

Pay Range

$77,313.60 - $115,980.80

Benefits

• 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

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.