Clinical Documentation Improvement Specialist (Hybrid), Day Shift, Clinical Documentation
Join to apply for the Clinical Documentation Improvement Specialist (Hybrid), Day Shift, Clinical Documentation role at Adventist HealthCare.
Work Schedule: Day Shift. Position Type: Hybrid. Location: Gaithersburg, MD.
Examine medical records to ensure documentation is accurate, complete, and reflective of the patient’s clinical status.
Detect inconsistencies, ambiguities, or missing information 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 collaborate with the coding/revenue cycle team.
Ensure documentation and provider queries align with regulatory standards, including CMS guidelines and organizational policies.
Communicate and establish relationships with physicians and clinical staff to share insights, trends, and education to improve documentation practices.
Contribute to organizational quality improvement initiatives 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.
Maintain and enhance current medical, coding and CDI knowledge via participating in continuing education offerings.
Qualifications
BSN or equivalent.
Registered Nurse with minimum of 5 years inpatient clinical experience and 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.
Benefits
Work life balance through non‑rotating shifts.
Recognition and rewards for professional expertise.
Free employee parking.
Medical, prescription, dental, and vision coverage for employees and eligible dependents effective on hire date.
Employer‑paid short‑ and 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 period.
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.
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.
COVID‑19 Vaccination: Adventist HealthCare strongly recommends all applicants to be fully vaccinated for COVID‑19 before commencing employment. Applicants may be required to furnish proof of vaccination.
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.
Join the Adventist HealthCare team today, apply now to be considered!