Clinical Documentation Improvement Specialist

Adventist HealthCare is a faith-based healthcare organization serving communities in Maryland for over a century, providing comprehensive medical services focused on physical, mental, and spiritual healing. The Clinical Documentation Improvement Specialist ensures accurate and compliant medical record documentation to support quality patient care and proper reimbursement. This role collaborates with physicians and coding teams to enhance documentation standards, regulatory compliance, and overall clinical data integrity.

Adventist HealthCare is seeking an experienced Clinical Documentation Improvement Specialist to support accurate, complete, and compliant clinical documentation practices. This position plays a key role in ensuring medical records accurately reflect patient conditions, support appropriate coding, and align with regulatory and reimbursement standards while promoting high-quality patient care.

Responsibilities:
- Review medical records to ensure documentation accurately reflects patient clinical status  
- Identify documentation inconsistencies or missing information and issue provider queries when needed  
- Verify documentation supports accurate ICD-10-CM/PCS and CPT coding in collaboration with revenue cycle teams  
- Ensure compliance with CMS guidelines and organizational documentation policies  
- Educate physicians and clinical staff on best practices to improve documentation quality  
- Track and report metrics related to documentation accuracy and query response rates  

Requirements:
- BSN or equivalent with active RN license  
- Minimum 5 years of inpatient clinical experience  
- 2–5 years of clinical documentation improvement experience  
- Relevant certification such as CDIP or CCDS  
- Working knowledge of Coding Clinic Guidelines and DRG systems  
- Strong understanding of medical terminology, anatomy, physiology, and disease processes  

Benefits:
- Medical, dental, and vision coverage from date of hire  
- Employer retirement contribution and matching program  
- Paid time off and tuition reimbursement  
- Employer-paid disability and life insurance  

Adventist HealthCare offers a supportive, mission-driven environment dedicated to delivering compassionate care and maintaining excellence in clinical documentation practices.