Clinical Documentation Specialist; Hybrid- Day Shift, Clinical Documentation

Fort Washington Medical Center

Adventist Health Care seeks to hire an experienced Clinical Documentation Improvement 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.
• Communicate and establish relationships with physicians and clinical staff to share insights, trends and education to improve documentation practices.
• Contribute 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.
• Maintain and enhance current medical, coding and CDI knowledge via participating in continuing education offerings.

• BSN or RN (Registered Nurse).
• Minimum of 5 years inpatient clinical experience with 2-5 years clinical documentation improvement experience.
• Experience with Solventum/3M 360 preferred.
• Current Maryland license.
• Relevant certification required, e.g. CDIP or CCDS.
• Maintains current working knowledge of Coding Clinic Guidelines and federal updates to DRG system (MS, APR, AP etc).
• Knowledge of medical terminology, anatomy, physiology, microbiology, and disease processes.

Full-time days, 40 hours per week;
Monday - Friday.

Hybrid and must be local to the Washington DC area.

Salary $71,932.12 - $.

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.

United States of America (Exempt)

• 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.

Our job is to care for you.

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

If you want to make a difference in someone’s life every day, consider a position with a team of professionals who are doing just that, making a difference.

Join the Adventist Health Care team today, apply now to be considered!

Adventist Health Care strongly recommends all applicants to be fully vaccinated for COVID-19 before commencing employment. Applicants may be required to furnish proof of vaccination.

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