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

Remote

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

 

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.

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.

Qualified candidates will possess:
• 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

As a faith-based organization, with over a century of caring for the communities in the Maryland area, Adventist HealthCare has earned a reputation for high-quality, compassionate care. Adventist HealthCare was the first and is the largest healthcare provider in Montgomery County.

If you want to make a difference