Clinical Documentation Improvement Lead, Day Shift, Patient Clinical Documentation

As a Clinical Documentation Improvement Lead, 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. • Support denial prevention and proactively learn and support documentation for medical necessity, clinical validation and partner with physician advisor/HIM/Coding as needed • Contributes to organizational quality improvement initiatives by ensuring robust and accurate documentation related to MHACs, PPCs, PSIs, SOI/ROM and mortality. • Maintain individual productivity and quality logs; contributes data for program metrics (query response rate, agreement rate, chart review volume). • Provide case specific education to the providers/clinical staff based on identified gaps escalating broader trends/needs to Lead. • 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. Qualifications include: • 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/week Typical Daily Schedule: 8 am-4 pm Monday through Friday Shift Type: Day Shift Holiday Requirements: Follow the company holiday calendar 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