Lead Clinical Documentation Integrity Specialist

Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect.

Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work.

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, looks 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 of the patient medical record and ensures it is in compliance with government and other regulations. Runs program(s) with moderate budget/impact. Participates in assigned committees.

Job Requirements:

Education and Work Experience

• 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

• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner Certificate (DIP): Required within two years of hire
• Current licensed RN, medical provider or equivalent: 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. Responsible for running reports. Responsible for denials review when required. Supports assigned market but will support other markets in the region as needed.
• Evaluates and assesses medical records of patients, looks 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 of the patient medical record.
• Analyzes and interprets medical records and clinical documentation and formulates appropriate physician queries. Reviews quality of medical record and communicates when conflicting data are found, the clinical documentation specialist (CDS) conveys deficiencies to the healthcare provider for more information to resolve the conflict.
• Acts as a liaison between the medical staff and other departments. Works collaboratively with physicians and other department staff to ensure that clinical information in the medical record is present and accurate so that the appropriate clinical diagnosis and level of severity is captured for the level of service rendered to 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. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.

Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.

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 more than 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.