Remote CDI Specialist – Elevate Clinical Documentation

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

Benefits offered by this job

Free Employee parking

Insurance: medical, dental, vision

Paid Time Off

Job summary

Adventist HealthCare seeks a Clinical Documentation Specialist to ensure documentation accuracy, support proper ICD-10-CM/PCS and CPT coding, and collaborate with physicians and the coding team. The role emphasizes regulatory alignment with CMS guidelines and ongoing education to improve documentation practices.

The ideal candidate will have clinical credentials (MD/DO/RN/Pharmacist/PT) and CDI certifications, with 5+ years inpatient experience and familiarity with ICD coding and audits.

Qualifications

• MD/DO or RN or other clinically licensed professional.
• RHIA/RHIT or related clinical degree.
• Minimum of 5 years inpatient clinical experience.
• 2+ years in 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.

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.

Skills

Inpatient experience

CDI knowledge

Physician communication

Regulatory compliance

ICD-10 coding

Query management

Education

MD/DO or equivalent

RHIA/RHIT or related degree

CDI certifications (CCDS/CDIP)

Tools

Solventum360

Job description

Adventist HealthCare seeks a Clinical Documentation Specialist to ensure documentation accuracy, support proper ICD-10-CM/PCS and CPT coding, and collaborate with physicians and the coding team. The role emphasizes regulatory alignment with CMS guidelines and ongoing education to improve documentation practices.

The ideal candidate will have clinical credentials (MD/DO/RN/Pharmacist/PT) and CDI certifications, with 5+ years inpatient experience and familiarity with ICD coding and audits.