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

Remote 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 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 TherapyRHIA, RHIT, or related clinical/allied health degree

Minimum of 5 years inpatient clinical experience2+ 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 preferredSolventum
360 preferredCCDS (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 - $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 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.

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