Remote
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
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
