Adventist HealthCare, Inc

Clinical Documentation Improvement Specialist (Remote), Day Shift, Clinical Documentation

Adventist HealthCare, Inc • $77K — $115K *
Hospitals & Medical Centers
5 - 7 years of experience
Job Overview by Ladders

Qualifications

  • Doctor of Medicine (MD), Doctor of Osteopathy (DO), Foreign Medical Graduate (FMG), Registered Nurse (RN), Pharmacist, or Doctor of Physical Therapy required.
  • RHIA, RHIT, or related clinical/allied health degree necessary.
  • Minimum of 5 years of inpatient clinical experience required.
  • 2+ years in clinical documentation, coding, case management, or acute-care clinical experience preferred.
  • Experience with ICD-10-CM/PCS, DRGs, SOI/ROM, or HCC is a plus.
  • Lean Six Sigma Green Belt preferred, along with familiarity with Solventum360.
  • CCDS or CDIP certification required or to be obtained within 90 days.

Responsibilities

  • Examine medical records for accuracy and completeness regarding patient clinical status.
  • Detect and address inconsistencies or missing information in medical records.
  • Verify clinical documentation supports correct coding for reimbursement.
  • Ensure documentation aligns with regulatory standards and organizational policies.
  • Communicate with physicians and clinical staff to improve documentation practices.
  • Contribute to quality improvement initiatives related to documentation accuracy.
  • Track and report metrics on documentation quality and query response rates.

Benefits

  • Work-life balance with nonrotating shifts.
  • Recognition and rewards for professional expertise.
  • Free employee parking.
  • Comprehensive medical, dental, and vision coverage effective on hire date.
  • Employer-paid short and long-term disability and basic life insurance.
  • Paid time off and retirement contributions after one year of service.
  • Tuition reimbursement and subsidized childcare options.
Full Job Description
Support Center

If you are a current Adventist HealthCare employee, please click this link to apply through your Workday account.

As a Clinical Documentation Specialist 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.
• 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.

Education and Experience:
• 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
  • Typical Daily Schedule: Monday through Friday
  • Shift Type: Day Shift-Remote
  • Weekend Requirements: No Weekends


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


About Adventist HealthCare, Inc

Adventist HealthCare is a non-profit healthcare organization that was founded in 1907 and is headquartered in Gaithersburg, Maryland. The organization operates a network of hospitals, clinics, and other healthcare facilities throughout Maryland and the Washington, D.C. metropolitan area. Adventist HealthCare is known for its commitment to providing high-quality, compassionate care to its patients and for its focus on community health and wellness. The organization has been recognized for its innovative programs and services, including its cancer care, heart and vascular care, and behavioral health services.
Learn more about Adventist HealthCare, Inc
Size
7,000 employees
Industry

Similar Jobs

More Jobs at Adventist HealthCare, Inc

More Hospitals & Medical Centers Jobs

Find similar Clinical Documentation Improvement Specialist (Remote), Day Shift, Clinical Documentation jobs: