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

Adventist HealthCare; United States; Remote; USD 77.000 - 116.000; Vollzeit

Benefits dieser Stelle

Work-life balance

Free parking

Medical, Dental, Vision coverage for员工

Zusammenfassung

Adventist HealthCare seeks a Clinical Documentation Specialist to ensure accurate, complete documentation reflecting patient status. You will query providers, verify ICD-10-CM/PCS and CPT coding, and support QA initiatives across CMS guidelines.

Role requires MD/DO/FMG/RN/Pharmacist/PT or equivalent, RHIA/RHIT or related degree, and 5+ years inpatient clinical experience with CDI exposure. Remote day shift with full-time schedule.

Qualifikationen

• MD/DO/FMG/RN/Pharmacist/PT or equivalent clinical degree.
• RHIA or RHIT or related degree.
• Minimum 5 years inpatient clinical experience.
• 2+ years in clinical documentation, coding, case management or related field.
• Experience interpreting physician documentation, labs, imaging and indicators.
• Experience with ICD-10-CM/PCS, DRGs, SOI/ROM or HCC is a plus.
• Lean Six Sigma Green belt preferred.
• Solventum360 preferred.
• CCDS/CDIP or equivalent required or within 90 days.

Aufgaben

• Examine medical records to ensure documentation is accurate, complete and reflective of patient status.
• Detect inconsistencies or missing information and request clarifications as needed.
• Verify documentation supports correct ICD-10-CM/PCS and CPT coding for reimbursement.
• Ensure alignment with CMS guidelines and organizational policies.
• Communicate with physicians and staff to share insights and educate on documentation.
• Contribute to quality improvement by ensuring robust documentation for MHACs, PPCs, PSIs and mortality.
• Track and report metrics related to documentation quality and query response rates.
• Provide guidance on best practices to physician and clinical staff.
• Assist in audits by ensuring proper documentation and addressing identified issues.
• Maintain and enhance CDI knowledge through continuing education.

Kenntnisse

Clinical documentation

Physician communication

Documentation auditing

Regulatory compliance

Education delivery

Ausbildung

MD/DO/FMG/RN/Pharmacist/PT or equivalent

RHIA or RHIT or related degree

Tools

ICD-10-CM/PCS

DRGs

SOI/ROM

HCC

Solventum360

CCDS/CDIP or equivalent

Jobbeschreibung

Support Center

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-Remote
• 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.

Applicants who wish to request accommodations for disabilities or religious belief should contact the Support Center HR Office.