Lead Clinical Documentation Integrity Specialist

Adventist Health is more than an award-winning health system. We provide whole-person care to our communities and champion the greater good - from the operating room to the boardroom, we are driven by our unique passion to live God's love through health, wholeness and hope. From Oregon to Oahu, we have a calling to always do more. Now is your chance to apply your passion to our mission.

We're looking for someone to join our team as a Lead Clinical Documentation Integrity Specialist who:

• Engages with physicians daily in both meetings and ad hoc to promote better working relationships between the Clinical Documentation Integrity team and providers. Manages, reviews, evaluates and assesses medical records of patients, looks for specificity of an illness, the accuracy of the clinician's documentation, coding requirements and documentation of important medical details to ensure the overall quality and completeness of clinical documentation of the patient medical record and ensures it is in compliance with government and other regulations. Runs program(s) with moderate budget/impact. Participates in assigned committees.

  Essential Functions:

  • Acts as a liaison between medical staff, other departments, and the CDI team to relay feedback. Attends onsite meetings in person to represent CDI. Responsible for new hire training. Responsible for running reports. Responsible for denials review when required. Supports assigned market but will support other markets in the region as needed. Evaluates and assesses medical records of patients, looks for specificity of an illness, the accuracy of the clinician's documentation, coding requirements and documentation of important medical details to ensure the overall quality and completeness of clinical documentation of the patient medical record.
  • Analyzes and interprets medical records and clinical documentation and formulates appropriate physician queries. Reviews quality of medical record and communicates when conflicting data are found, the clinical documentation specialist (CDS) conveys deficiencies to the healthcare provider for more information to resolve the conflict. Acts as a liaison between the medical staff and other departments. Works collaboratively with physicians and other department staff to ensure that clinical information in the medical record is present and accurate so that the appropriate clinical diagnosis and level of severity is captured for the level of service rendered to all patients.
  • Keeps abreast of regulatory changes related to documentation and coding and communicates these changes to appropriate staff. Follows documentation guidelines and legal requirements to ensure compliance with federal and state regulatory bodies.
  • Performs other job-related duties as assigned.

You'll be successful with the following qualifications:

Education:

• Associate's/Technical Degree or equivalent combination of education/related experience: Required
• Bachelor's degree or equivalent combination of education/related experience: Required
• Master's degree: Preferred
  

Work Experience:

• Five years clinical documentation integrity experience: Required
• Three years clinical experience: Required
  

Required Licenses/Certifications:

• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP): Required within two years after hireRefer to the Required Licenses and Certifications list for additional job and/or unit specific requirements.
• Current licensed RN, medical provider or equivalent: Required
  

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations, including, but not limited to, measles, mumps, flu (based on the seasonal availability of the flu vaccine typically during October-March each year), COVID-19 vaccine (required in CA, HI and OR) etc., as a condition of employment, and annually thereafter. Medical and religious exemptions may apply.

The estimated base pay for this position is $54.68 to $81.95. Additional individual compensation may be available for this role through years of experience, differentials, extra shift incentives, bonuses, etc. Base pay is only a portion of the total rewards package, and a comprehensive benefits program is available for qualifying positions. Please contact our Talent Acquisition team for more information.