Clinical Documentation Integrity Specialist - Per Diem (Remote)

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.

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. 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 ensure it is in compliance with government and other regulations. Works on problems of moderate to diverse scope requiring some interpretation of policies and guidelines. Applies working knowledge of the techniques, principles, theories and concepts to complete routine and non-routine assignments. Runs program(s) with moderate budget/impact.

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. Performs coding, working DRG assignment and enters all review activity into tracking software. Analyzes and interprets medical records and clinical documentation and formulates appropriate physician queries. Performs follow up on incomplete physician queries to obtain an answer while the patient is still in house. Updates “working DRG” as documentation supports, or physician query answer supports a change in the DRG assignment. Reviews quality of medical record and communicates when conflicting data are found, the clinical documentation integrity specialist (CDIS) conveys deficiencies to the department lead for more information to resolve the conflict. Keeps abreast of regulatory changes related to documentation, coding and communicate these changes to appropriate staff. Follows documentation guidelines and legal requirements to ensure compliance with federal and state regulatory bodies. Attends ongoing education sessions. Acts as a liaison between the medical staff and the coding department. Works collaboratively with physicians and coding 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. Attends scheduled physician and care management meetings as requested and reviews requested cases prior to the meetings. Performs other job-related duties as assigned.