Lead Clinical Documentation Specialist (Hybrid), Day Shift, Clinical Documentation

Support Center

If you are a current Adventist HealthCare employee, please click this link to apply through your Workday account.

 

Adventist HealthCare Support Center seeks to hire an experienced Lead Clinical Documentation Specialist who will embrace our mission to extend God’s care through the ministry of physical, mental, and spiritual healing.

As a Lead Clinical Documentation Specialist you will:
• Run daily operations for assigned sites: staffing coverage, workload/meeting cadence, workload balancing, weekend/holiday coverage plan. 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. Reviews and validates CDI impact charts to confirm accuracy
• Provide real-time clinical review for tough cases (ICU acuity, procedures, cardiology/cardiac surgery, sepsis/resp failure, shock, encephalopathy, malnutrition, etc.) and escalate as appropriate to ensure there is appropriate SOI/ROM
• Review department data for quality and accuracy, identifying trends, systemic issues and factors contributing to inaccurate data impacting quality and patient safety
• Conducts 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
• Collaborate with Quality reviewer to go over MHAC, PSI, PPC documentation risks
• 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
• Assisting and supporting leadership in planning, directing, and controlling all aspects of the day-to-day events in CDI department

Qualifications include:
• Doctor of Medicine (MD), Doctor of Osteopathy (DO), Foreign Medical Graduate (FMG), Registered Nurse (RN), Doctor of Physical Therapy, Pharmacist
• RHIA, RHIT, or related clinical/allied health degree
• Minimum of 7 years inpatient clinical experience
• 2+ years of clinical documentation, coding, case management, utilization review, or acute-care clinical experience
• Experience interpreting physician documentation, lab results, imaging, and clinical indicators.
• Experience with ICD-10-CM/PCS, DRGs, SOI/ROM or HCC is a plus
• Lean Six Sigma Green belt preferred
• Solventum360 preferred
• CCDS (Certified Clinical Documentation Specialist), CDIP (Clinical Documentation Improvement Practitioner) or equivalent required and active
• Certified Documentation Expert Inpatient (CDEI) preferred
• Certified Coding Specialist (CCS) preferred
• 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.
• Proficient in Microsoft office

Work Schedule:

Employment Type: Full-time
Hours per Week: 40 hours
Typical Daily Schedule: Monday through Friday 
Shift Type: Day Shift

Weekend Requirements: No Weekends
Holiday Requirements: Follow company holiday calendar
Competitive Performance Incentive: Eligible

Hybrid, requires occasional travel to AHC hospitals and support center for meetings, learning sessions, workgroups.

Pay Range:

$89,356.80 - $134,035.20

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 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

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 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.

 

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.