Clinical Documentation Improvement Specialist (...
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Adventist HealthCare seeks to hire an experienced Clinical Documentation Improvement Specialist who will embrace our mission to extend Godâs 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 patientâs 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. Qualifications include:⢠BSN or EquivalentRN (Registered Nurse)⢠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.Work Schedule:Employment Type: Full-time
Hours per Week: 40 hours
Typical Daily Schedule:Â Monday through FridayÂ
Shift Type:Â Day Shift
Weekend Requirements:Â No Weekends
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:- 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 periodÂ
- 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