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

Adventist HealthCare • Gaithersburg, MD

6d • Hybrid

About The Position

Adventist HealthCare 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. As a Clinical Documentation Improvement 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.

Requirements

• BSN or Equivalent RN (Registered Nurse)
• Minimum of 5 years inpatient clinical experience with 2-5 years clinical documentation improvement experience
• 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.

Nice To Haves

• Experience with Solventum/3M 360 preferred

Responsibilities

• 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.

Benefits

• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees