Clinical Documentation Integrity Specialist (Hybrid - Portland, OR)

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. 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 enjoy a welcoming space designed to promote well-being and inspire your best work.

About the Role

Reviews, evaluates, and assesses medical records of patients to ensure the specificity of an illness, accuracy of clinician’s documentation, coding requirements, and completeness of clinical documentation. Works on problems of moderate to diverse scope, applying working knowledge of techniques, principles, and theories to complete routine and non-routine assignments. Manages programs with moderate budget and impact.

Responsibilities

• Evaluates and assesses medical records for specificity of illness, accuracy of clinician’s documentation, coding requirements, and important medical details to ensure quality and completeness of clinical documentation.
• Performs coding, assigns working DRGs, and enters all review activity into tracking software.
• Analyzes and interprets medical records and clinical documentation, formulating appropriate physician queries.
• Follows up on incomplete physician queries to obtain answers while the patient is still in-house.
• Updates “working DRG” as documentation or physician query answers support a change in DRG assignment.
• Reviews quality of medical records and communicates conflicting data to the department lead for resolution.
• Stays abreast of regulatory changes related to documentation and coding, communicating these changes to appropriate staff.
• Ensures compliance with federal and state regulatory bodies by following documentation guidelines and legal requirements.
• Attends ongoing education sessions.
• Acts as a liaison between medical staff and the coding department, collaborating with physicians and coding staff to ensure accurate clinical information and appropriate clinical diagnosis.
• Attends scheduled physician and care management meetings as requested, reviewing cases prior to meetings.
• Performs other job-related duties as assigned.

Requirements

• Associate's/Technical Degree or equivalent combination of education/related experience: Required
• Bachelor's Degree: Preferred
• Three years' clinical experience: Required
• Two years' clinical documentation experience: Required

Qualifications

• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner Certificate (DIP): Required
• Current licensed RN, medical provider, or equivalent: Required

Pay

The estimated base pay for this position is $50.51 to $75.71 per hour. Additional individual compensation may be available through differentials, extra shift incentives, bonuses, etc. Base pay is only a portion of the total rewards package, and a comprehensive benefits program is available for qualifying positions.

Schedule

• Full-time regular
• Day Shift
• 8-hour shifts