Clinical Documentation Improvement Specialist, Day Shift, Clinical Documentation
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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.
Education and Experience:
•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.
•Experience with ICD-10-CM/PCS, DRGs, SOI/ROM or HCC is a plus
•Lean Six Sigma Green belt preferred
•Solventum360 preferred
•CCDS (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:
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Employment Type: Full-time
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Hours per Week: 40 hours
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Typical Daily Schedule: Monday through Friday
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Shift Type: Day Shift
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Weekend Requirements: No Weekends
Pay Range:
$77,313.60 - $115,980.80
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 HealthCare our job is to care for you.
We do this by offering:
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Work life balance through nonrotating shifts
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Recognition and rewards for professional expertise
- Free Employee parking
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Medical, Prescription, Dental, and Vision coverage for employees and their eligible dependents effective on your date of hire
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Employer-paid Short & Long-Term Disability, Basic Life Insurance and AD&D, (short-term disability buy-up available)
- Paid Time Off
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Employer retirement contribution and match after 1-year of eligible employment with a 3-year vesting period
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Voluntary benefits include flexible spending accounts, legal plans, and life, pet, auto, home, long term care, and critical illness & accident insurance
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Subsidized childcare at participating childcare centers
- Tuition Reimbursement
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Employee Assi