Senior Clinical Documentation Improvement Lead

Adventist HealthCare; Gaithersburg (MD); Presencial; USD 77.000 - 116.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Medical coverage

Paid time off

Retirement plan with match

Descripción de la vacante

Adventist HealthCare is seeking an experienced Clinical Documentation Improvement Lead for the Support Center to ensure accurate, complete documentation reflecting patient status. You will work with physicians and clinical staff to educate and improve documentation practices, support medical necessity validation, and participate in audits and quality initiatives.

The role requires strong inpatient CDI experience, CCDS/CDIP or equivalent, and relevant certifications, with a focus on CMS

Formación

• MD/DO/RN/Pharmacist/Doctor of Physical Therapy degree required.
• RHIA/RHIT or related clinical degree, or equivalent, preferred or within 90 days.
• Minimum of 5 years inpatient clinical experience.
• 2+ years in clinical documentation, coding, case management, utilization review, or acute-care clinical experience.
• CCDS/CDIP or equivalent certification required or within 90 days; Lean Six Sigma Green Belt preferred.

Responsabilidades

• Examine medical records to ensure documentation reflects patient’s clinical status.
• Detect inconsistencies, ambiguities, or missing information and request provider clarifications as necessary.
• Verify that documentation supports correct ICD-10-CM/PCS and CPT coding for proper reimbursement; collaborate with coding/revenue cycle teams.
• Communicate with physicians and clinical staff to share insights, trends, and education to improve documentation practices.
• Support denial prevention and contribute to documentation for medical necessity and clinical validation; participate in audits and education.

Descripción del empleo

Adventist HealthCare is seeking an experienced Clinical Documentation Improvement Lead for the Support Center to ensure accurate, complete documentation reflecting patient status. You will work with physicians and clinical staff to educate and improve documentation practices, support medical necessity validation, and participate in audits and quality initiatives.

The role requires strong inpatient CDI experience, CCDS/CDIP or equivalent, and relevant certifications, with a focus on CMS