Lead Clinical Documentation Integrity Specialist; Hybrid - Portland

Overview

Lead Clinical Documentation Integrity Specialist (Hybrid - Portland, OR)

Join to apply for the Lead Clinical Documentation Integrity Specialist role at Adventist Health Portland.

Adventist Health Portland is a leading healthcare provider in the area, with a collaborative relationship with OHSU and a network that includes a 302-bed hospital, 11 medical offices, home care services, comprehensive cancer care, and additional award-winning services across East Portland and surrounding areas.

Engages with physicians daily in meetings and ad hoc to promote better working relationships between the Clinical Documentation Integrity (CDI) team and providers. Manages, reviews, evaluates and assesses medical records to identify specificity of illness, accuracy of clinician documentation, coding requirements, and documentation of key medical details to ensure overall quality and completeness of clinical documentation in the patient medical record, in compliance with government and other regulations.

Runs programs with moderate budget/impact. Participates in assigned committees.

• Act as a liaison between medical staff, other departments, and the CDI team; attend onsite meetings in person to represent CDI; participate in new hire training; run reports; conduct denials review as needed; support the assigned market and other markets in the region as needed.
• Evaluate and assess medical records to ensure specificity of illness, accuracy of documentation, and compliance with coding requirements and essential medical details.
• Analyze and interpret medical records and clinical documentation; formulate appropriate physician queries; review quality of the medical record and communicate deficiencies to healthcare providers for resolution.
• Collaborate with physicians and department staff to ensure clinical information is present and accurate, capturing the appropriate clinical diagnosis and level of severity for the service rendered.
• Stay informed of regulatory changes related to documentation and coding; communicate changes to staff; follow documentation guidelines and legal requirements to ensure regulatory compliance.
• Perform other job-related duties as assigned.

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:

• Current licensed RN, medical provider or equivalent:
  Required
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner Certificate (DIP):
  Required
• Foreign Medical Doctor (FMD) or Medical license MD (MD) or Registered Nurse (RN):
  Required

• Acts as a liaison between medical staff, other departments, and the CDI team to relay feedback; attends onsite meetings to represent CDI; responsible for new hire training; responsible for running reports; responsible for denials review when required; supports assigned market and other markets in the region as needed.
• Evaluates and assesses medical records to ensure specificity and accuracy of clinical documentation and coding requirements.
• Analyzes and interprets medical records; formulates physician queries; communicates deficiencies to providers to resolve conflicts in documentation.
• Keeps abreast of regulatory changes related to documentation and coding; ensures compliance with federal and state regulatory bodies.
• Performs other job-related duties as assigned.

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.

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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.