Job Summary:
Assists with ensuring accurate and complete documentation in the medical record to support quality measures and coding accuracy. Working under the direction of quality leader, this role reviews patient records, recommends provider queries using established templates, and helps ensure documentation supports appropriate coding. Supports the Quality teams by performing chart reviews, following up on query responses, and assisting with documentation improvement initiatives. Works collaboratively with providers, quality, CDI and coding staff to address documentation gaps and supports data integrity efforts.
Job Requirements:
Education and Work Experience:
- Associate's/Technical Degree in Nursing, Health Information Management, or related clinical field or equivalent combination of education/related experience: Required
- Bachelor's Degree: Preferred
- Three years' CDI/clinical documentation experience OR coding experience: Required
- Two years' clinical experience: Required
- Familiarity with PSI/HAC validation, mortality reviews and external quality reporting. Exposure to risk adjustment concepts (HCC, SOI/ROM). Experience communicating with providers.: Preferred
Licenses/Certifications:
- RN OR LPN OR RHIT OR CCS, or equivalent: Required
- Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner Certificate (DIP): within 12 months of hire
- Current licensed RN, medical provider or equivalent: Required
Essential Functions:
- Performs chart reviews of inpatient medical records following established criteria and checklists. Identifies documentation gaps and flag cases requiring clarification. Drafts provider queries using approved templates when clarification is needed.
- Assists with case reviews to support coding accuracy for quality measures. Works with CDI & coding professionals and quality teams as directed. Helps track documentation issues that may impact quality reporting.
- Communicates with physicians and clinical staff regarding documentation clarification requests. Provides real-time feedback and education to clinicians on documentation best practices. Serves as a liaison between quality, coding, and clinical teams to resolve documentation issues.
- Assists with educational materials and resources on documentation best practices. Supports CDI staff with training preparation as needed.
- Stays current on CDI best practices and apply learnings to daily work. Participates in audits and metrics tracking as assigned. Supports continuous improvement efforts within the quality program.
- Performs other job-related duties as assigned.
Organizational Requirements:
Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.
