Lead Clinical Documentation Integrity Specialist

Adventist Health • Bakersfield, CA

7d

About The Position

Located at Adventist Health’s corporate headquarters in Roseville, California, this role engages with physicians through regular meetings and ad hoc interactions to strengthen relationships between providers and the Clinical Documentation Integrity (CDI) team. The specialist reviews and assesses patient medical records for illness specificity, documentation accuracy, coding requirements, and important clinical details, supporting complete, high-quality records that comply with applicable regulations. The role runs program(s) with moderate budget or impact and participates in assigned committees.

The specialist serves as a liaison among medical staff, other departments, and the CDI team; trains new hires; runs reports; and conducts denials reviews when required. The position supports an assigned market and other regional markets as needed. It involves analyzing clinical records, formulating physician queries, communicating documentation deficiencies or conflicts to providers, and working with physicians and department staff to ensure diagnoses and severity are appropriately documented for the services provided. The specialist also monitors regulatory changes related to documentation and coding and communicates them to relevant staff.

Requirements

• Associate's/Technical Degree or equivalent combination of education and related experience.
• Bachelor's degree or equivalent combination of education and related experience.
• Five years of clinical documentation integrity experience.
• Three years of clinical experience.
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (DIP) certificate required within two years of hire.
• Current licensed RN, medical provider, or equivalent.

Responsibilities

• Engage with physicians in meetings and ad hoc interactions to promote effective working relationships between providers and the CDI team.
• Act as a liaison between medical staff, other departments, and the CDI team, relaying feedback.
• Attend onsite meetings in person to represent CDI.
• Train new hires.
• Run reports.
• Conduct denials reviews when required.
• Support the assigned market and other markets in the region as needed.
• Evaluate and assess patient medical records for illness specificity, documentation accuracy, coding requirements, and important medical details.
• Analyze and interpret medical records and clinical documentation and formulate appropriate physician queries.
• Review medical-record quality and convey deficiencies or conflicting data to healthcare providers for clarification.
• Collaborate with physicians and other department staff to ensure clinical information is present and accurate so diagnoses and severity are captured appropriately for the services rendered.
• Keep abreast of regulatory changes related to documentation and coding and communicate changes to appropriate staff.
• Follow documentation guidelines and legal requirements to ensure compliance with federal and state regulatory bodies.
• Perform other job-related duties as assigned.
• Run program(s) with moderate budget or impact and participate in assigned committees.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Associate degree