Clinical Documentation Improvement Specialist (Remote), Day Shift, Clinical Documentation
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. 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.
Requirements
- Bachelor degree or equivalent
- RN (Registered Nurse) preferred
- 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.
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
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
