Remote Clinical Documentation Improvement Specialist

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 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