Remote Clinical Documentation Improvement Specialist

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

Benefits offered by this job

Work-life balance

Free parking

Medical, Dental, Vision coverage for员工

Job summary

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.

Qualifications

• 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.

Responsibilities

• 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.

Skills

Clinical documentation

Physician communication

Documentation auditing

Regulatory compliance

Education delivery

Education

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

Job description

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.