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

Adventist HealthCare • Gaithersburg, MD

3d • $77,314 - $115,981 • Remote

About The Position

Adventist HealthCare 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. This role involves examining medical records to ensure documentation is accurate, complete, and reflective of the patient’s clinical status. The specialist will detect inconsistencies, ambiguities, or missing information that may impact coding, compliance, or patient care, and will request provider clarifications as necessary. A key responsibility is verifying that clinical documentation supports correct ICD-10-CM/PCS and CPT coding for proper reimbursement and collaborating with the coding/revenue cycle team. The role also ensures that documentation and provider queries align with regulatory standards, including CMS guidelines and organizational policies. Communication and relationship-building with physicians and clinical staff are crucial for sharing insights, trends, and education to improve documentation practices. The specialist will contribute to organizational quality improvement initiatives by ensuring robust and accurate documentation related to MHACs, PPCs, PSIs, SOI/ROM and mortality. Tracking and reporting on metrics related to documentation quality, such as query response rates or documentation accuracy, is also part of the role. Providing guidance and education on documentation best practices and standards to physician and clinical staff supports ongoing improvement. The specialist will assist in internal and external audits by ensuring proper documentation and addressing identified issues. Maintaining and enhancing current medical, coding, and CDI knowledge via participating in continuing education offerings is essential.

Requirements

• 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.
• CCDS (Certified Clinical Documentation Specialist), CDIP (Clinical Documentation Improvement Practitioner) or equivalent required or within 90 days

Nice To Haves

• Experience with ICD-10-CM/PCS, DRGs, SOI/ROM or HCC is a plus
• Lean Six Sigma Green belt preferred
• Solventum360 preferred
• Certified Documentation Expert Inpatient (CDEI)
• Certified Coding Specialist (CCS)

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: Senior