Clinical Documentation Improvement Specialist

Responsibilities

• Examine medical records to ensure documentation is accurate, complete, and reflective of the patient's clinical status
• Detect inconsistencies, ambiguities, or missing information and request provider clarifications
• Verify clinical documentation supports correct ICD-10-CM/PCS and CPT coding for reimbursement
• Ensure documentation and provider queries align with regulatory standards and CMS guidelines
• Establish relationships with physicians and clinical staff to share insights and education
• Contribute to quality improvement initiatives related to mortality and clinical indicators
• Track and report on metrics related to documentation quality and accuracy
• Provide guidance on documentation best practices to clinical staff
• Assist in internal and external audits

Requirements

• MD, DO, FMG, RN, Pharmacist, or Doctor of Physical Therapy degree
• RHIA, RHIT, or related clinical/allied health degree
• Minimum 5 years inpatient clinical experience
• 2+ years of clinical documentation, coding, case management, or utilization review experience
• Experience interpreting physician documentation, lab results, imaging, and clinical indicators
• CCDS or CDIP certification (or obtained within 90 days)

Preferred Qualifications

• Experience with ICD-10-CM/PCS, DRGs, SOI/ROM or HCC
• Lean Six Sigma Green belt
• Solventum360 experience
• CDEI or CCS certifications

Benefits

• Medical, Prescription, Dental, and Vision coverage effective on date of hire
• Paid Time Off and employer retirement contribution with match after 1 year
• Tuition Reimbursement and Employee Assistance Program (EAP)
• Subsidized childcare at participating centers

About the Company

Aventist HealthCare is a faith-based, not-for-profit organization dedicated to improving the health and well-being of communities through physical, mental, and spiritual healing.