Clinical Documentation Improvement Lead, Day Shift, Patient Clinical Documentation

Support Center If you are a current Adventist Health Care employee, please click this link to apply through your Workday account.

Adventist Health Care seeks to hire an experienced Clinical Documentation Improvement Lead for our Support Center who will embrace our mission to extend God’s care through the ministry of physical, mental, and spiritual healing.

As a Clinical Documentation Improvement Lead, 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.
• Support denial prevention and proactively learn and support documentation for medical necessity, clinical validation and partner with physician advisor/HIM/Coding as needed
• Contributes to organizational quality improvement initiatives by ensuring robust and accurate documentation related to MHACs, PPCs, PSIs, SOI/ROM and mortality.
• Maintain individual productivity and quality logs; contributes data for program metrics (query response rate, agreement rate, chart review volume).
• Provide case specific education to the providers/clinical staff based on identified gaps escalating broader trends/needs to Lead.
• 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 include:
• 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
• Solventum
360 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/week Typical Daily

Schedule:

8 am-4 pm Monday through Friday Shift Type:
Day Shift Holiday Requirements:
Follow the company holiday calendar

Pay Range:$77,313.60 - $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 Health Care 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…