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

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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.
• 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.

• BSN or Equivalent 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.

Day Shift

Hybrid Position

$71,932.12 - $

United States of America (Exempt)

At Adventist Health Care our job is to care for you.

• 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 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.

Tobacco use is a well-recognized preventable cause of death in the United States and an important public health issue. In order to promote and maintain a healthy work environment, Adventist Health Care will not hire applicants for employment who either state that they are…