Clinical Documentation Improvement Lead, Day Shift, Patient Clinical Documentation

Support Center If you are a current Adventist HealthCare employee, please click this link to apply through your Workday account. Adventist Healthcare seeks to hire an experienced Clinical Documentation Improvement Lead for our Support Center who will embrace our mission to extend God’s care through the ministry of physical, mental, and spiritual healing. As a Clinical Documentation Improvement Lead, you will: •Develops, implements, and maintains formal and informal CDI education & training on clinical documentation and CDI software for a variety of disciplines, utilizing multiple approaches based on identified needs •Review department data for quality and accuracy, identifying trends, systemic issues, and factors contributing to inaccurate data impacting quality and patient safety •Perform monthly department compliance audits and report on key performance indicators to include -PPC/HACS-PSI 90/Mortality Reviews educational programs related to documentation improvement opportunities, coding, and reimbursement issues, as well as performance improvement methodologies for internal customers and physicians. • Analyzes and compiles accurate and complete data for statistical reporting and educational presentations, as needed. •Communicates and interacts with physicians and clinical staff via informal verbal communication, the use of written communication tools, and formal educational presentations. •Utilizes research, analytic data, and observations to provide recommendations to improve the overall quality and completeness of clinical documentation. •Analyzes, summarizes, and documents outcomes of the documentation improvement process for re-evaluation of ongoing program revisions. •Participates as a member of work groups related to clinical documentation, utilization, and compliance, if required. •Establishes cooperative and multidisciplinary relationships with physicians, coding staff, and other health team members. • Acts as a resource to the CDI department and health team members related to optimal documentation, educational needs, and successful problem resolution. •Familiarity with APR-DRG’s and Inpatient Prospective Payment System (IPPS), including new CMS guidelines of key elements including clinical documentation of what constitutes an inpatient admission. •Along with familiarity and the ability to effectively communicate the use of various coding systems and Official Coding Guidelines. •Performs concurrent and retrospective reviews of the medical record (as needed), utilizing evidence-based knowledge, protocols, and criteria. •Facilitates modifications to support clinical documentation of health team members to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a focus on physician documentation, inpatients, and DRG payers. •Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes. •Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart. •Maintains and enhances current medical, coding, and CDI knowledge via participating in continuing education offerings. •Effective ability to communicate the benefits of complete and accurate documentation to physicians relating to their daily practice of medicine. •Performs audits on physician documentation, using the template provided by the HIM committee, on both initial and concurrent documents. •Participates in second-level MHAC reviews and attends MHAC steering committee meetings monthly Qualifications include: Registered Nurse •5 years of patient care in a hospital setting. •3-5 years of CDI experience •Verified current Maryland or other compact state RN license • Active American Heart Association Basic Life Support (BLS) certification required Work Schedule: Monday through Friday 8 am to 4 pm #GR8 Other 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 403(b) retirement plan Free Employee parking Benefits Eligible Positions: Competitive, comprehensive benefit plans [including health, employer-paid disability and life insurance, PTO] Employer retirement contribution and match after 1-year of eligible employment with 3 year vesting Ancillary benefits such as flexible spending, legal and pet insurance to meet the needs of employees and their eligible family members Subsidized childcare at participating childcare centers As a faith-based organization, with over a century of caring for the communities in the Maryland area, Adventist HealthCare has earned a reputation for high-quality, compassionate care. Adventist HealthCare was the first and is the largest healthcare provider in Montgomery County. If you want to make a difference in someone’s life every day, consider a position with a team of professionals who are doing just that, making a difference. Join the Adventist HealthCare team today, apply now to be considered! COVID-19 Vaccination Adventist HealthCare requires all applicants to be fully vaccinated for COVID-19 before commencing employment. Applicants may be required to furnish proof of vaccination and, if needed, may elect to be vaccinated at any community pharmacy or location offering COVID-19 vaccinations. Tobacco and Drug Statement Tobacco use is a well-recognized preventable cause of death in the United States and an important public health issue. In order to promote and maintain a healthy work environment, Adventist HealthCare will not hire applicants for employment who either state that they are nicotine users or who test positive for nicotine and drug use. While some jurisdictions, including Maryland, permit the use of marijuana for medical purposes, marijuana continues to be classified as an illegal drug under the federal Controlled Substances Act. As a result, medical marijuana use will not be accepted as a valid explanation for a positive drug test result. Adventist HealthCare will withdraw offers of employment to applicants who test positive for Cotinine (nicotine) and marijuana. Those testing positive are given the opportunity to re-apply in 90 days, if they can truthfully attest that they have not used any nicotine products in the past ninety (90) days and successfully pass follow-up testing. ("Nicotine products" include, but are not limited to: cigarettes, cigars, pipes, chewing tobacco, e-cigarettes, vaping products, hookah, and nicotine replacement products (e.g., nicotine gum, nicotine patches, nicotine lozenges, etc.). Equal Employment Opportunity Adventist HealthCare is an Equal Opportunity/Affirmative Action Employer. We are committed to attracting, engaging, and developing the best people to cultivate our mission-centric culture. Our goal is to have a welcoming, equitable, and safe place to work and grow for all employees, no matter their background. AHC does not discriminate in employment opportunities or practices on the basis of race, ethnicity, color, religion, sex, national origin, age, disability, sexual orientation, gender identity, pregnancy and related medical conditions, protected veteran status, or any other characteristic protected by law. Adventist HealthCare will make reasonable accommodations for applicants with disabilities, in accordance with applicable law. Adventist HealthCare is a religious organization as defined under applicable law; however, it will endeavor to provide reasonable accommodations for applicants’ religious beliefs. Applicants who wish to request accommodations for disabilities or religious belief should contact the Support Center HR Office. Our Mission: We extend God's care through the ministry of physical, mental and spiritual healing. Adventist HealthCare, based in Gaithersburg, MD., is a faith-based, not-for-profit organization of dedicated professionals who work together each day to improve the health and well-being of people and communities through a ministry of physical, mental and spiritual healing. Our comprehensive approach to caring for our community includes three acute-care hospitals – Shady Grove Medical Center, White Oak Medical Center and Fort Washington Medical Center – as well as two Physical Rehabilitation hospitals, Outpatient centers, Imaging Centers, Urgent Cares, Home Care Services, Employer Health Programs and Physician Networks. We are nationally recognized and honored especially for our Cardiac, OB, Cancer, Stroke, Orthopedic, Rehabilitation and Mental Health services. Consider joining our team of over 6,000 employees and become part of one of the longest serving healthcare systems in the Washington, D.C., area that has a long-standing tradition as the largest provider of charity care and community benefit in Montgomery County. Notice of E-Verify Participation