[Hiring] Clinical Documentation Improvement Specialist @Adventist HealthCare

Role Description

Adventist HealthCare seeks to hire a Clinical Documentation Specialist who will embrace our mission to extend God’s care through the ministry of physical, mental and spiritual healing.

• 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 initiatives 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.

Qualifications

• 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).

Requirements

• Full-time employment.
• 40 hours per week.
• Typical daily schedule: Monday through Friday.
• Shift type: Day Shift-Remote.
• Weekend requirements: No Weekends.
• Pay range: $77,313.60 - $115,980.80.

Benefits

• 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.