Lead Clinical Documentation Integrity Specialist (Hybrid - Portland, OR)
Adventist Health Portland |
Full-time
Portland
Negotiable
Advanced (5-10 yrs)
Job Description
In a bustling cosmopolitan area surrounded by nature, Adventist Health Portland has been one of the area’s leading healthcare providers since the 1800s. In partnership with OHSU, we are comprised of a 302‑bed hospital, 11 medical offices, home‑care services, comprehensive cancer care and a vast scope of award‑winning services located throughout East Portland and the surrounding areas. There are many outdoor adventures readily available, including carving the snow at North America’s only year‑round ski resort, hiking along the Columbia River Gorge or taking a day trip to the unmatched beauty of the Oregon coast.
Job Summary
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, looking 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 and ensures compliance with government and other regulations. Runs program(s) with moderate budget/impact and participates in assigned committees.
Job Requirements
Associate’s/Technical Degree or equivalent combination of education/related experience: Required
Bachelor’s degree or equivalent combination of education/related experience: Required
Five years’ clinical documentation integrity experience: Required
Three years’ clinical experience: Required
Licenses & Certifications
Current licensed RN, medical provider or equivalent: Required
Foreign Medical Doctor (FMD) or Medical licence MD (MD) or Registered Nurse (RN): Required
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, running reports, and denials review as required; supports assigned market and other markets in the region as needed.
Evaluates and assesses medical records of patients, looking for specificity of an illness, the accuracy of the clinician’s documentation, coding requirements and documentation of important medical details to ensure overall quality and completeness of the patient medical record.
Analyzes and interprets medical records and clinical documentation, formulates appropriate physician queries, and reviews quality of the record—communicating when conflicting data are found.
Works collaboratively with physicians and other departments to ensure clinical information in the medical record is present and accurate, capturing appropriate clinical diagnosis and level of severity for 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.
Organizational Requirements
Adventist Health is committed to the safety and wellbeing of our associates and patients. All associates receive required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.
Adventist Health participates in E‑Verify. By applying, you acknowledge that you have read the E‑Verify Participation and Right to Work notices.
About Us
Adventist Health is a faith‑based, nonprofit, integrated health system serving more than 100 communities on the West Coast and Hawaii with over 440 sites of care, including 27 acute care facilities. Founded on Adventist heritage and values, Adventist Health provides care in hospitals, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of over 38,000 includes employees, physicians, medical staff, and volunteers driven in pursuit of one mission: living God’s love by inspiring health, wholeness and hope.