Adventist Health

Faith-based nonprofit integrated health system

Clinical Documentation Integrity Specialist

Clinical Support & Patient AdministrationConfirmed live in the last 24 hours

Full-timeRoseville, CA, USAIn-person

About the Job

Requirements

An Associate's or technical degree in Nursing, Health Information Management, or a related clinical field, or an equivalent combination of education and related experience, is required.
At least three years of CDI/clinical documentation experience or coding experience is required.
At least two years of clinical experience is required.
Familiarity with PSI/HAC validation, mortality reviews, and external quality reporting is preferred.
Exposure to risk adjustment concepts, including HCC and SOI/ROM, is preferred.
Experience communicating with providers is preferred.
An RN, LPN, RHIT, CCS, or equivalent credential is required.
A current RN license, medical provider credential, or equivalent is required.
A Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (DIP) certificate must be obtained within 12 months of hire.
Associates must receive required vaccinations as a condition of employment and annually thereafter where applicable; medical and religious exemptions may apply.

Responsibilities

Review inpatient medical records using established criteria and checklists, identify documentation gaps, flag cases requiring clarification, and draft provider queries using approved templates.
Assist with case reviews to support coding accuracy for quality measures, work with CDI and coding professionals and quality teams as directed, and track documentation issues that may affect quality reporting.
Communicate with physicians and clinical staff about documentation clarification requests, provide real-time feedback and education on documentation best practices, and serve as a liaison among quality, coding, and clinical teams to resolve documentation issues.
Assist with educational materials and resources on documentation best practices and support CDI staff with training preparation as needed.
Stay current on CDI best practices and apply learnings to daily work; participate in audits and metrics tracking as assigned; support continuous improvement efforts within the quality program.
Perform other job-related duties as assigned.

Desired Qualifications

A Bachelor's degree is preferred.

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:

Assists with ensuring accurate and complete documentation in the medical record to support quality measures and coding accuracy. Working under the direction of quality leader, this role reviews patient records, recommends provider queries using established templates, and helps ensure documentation supports appropriate coding. Supports the Quality teams by performing chart reviews, following up on query responses, and assisting with documentation improvement initiatives. Works collaboratively with providers, quality, CDI and coding staff to address documentation gaps and supports data integrity efforts.

Job Requirements:

Education and Work Experience:

Associate's/Technical Degree in Nursing, Health Information Management, or related clinical field or equivalent combination of education/related experience: Required
Bachelor's Degree: Preferred
Three years' CDI/clinical documentation experience OR coding experience: Required
Two years' clinical experience: Required
Familiarity with PSI/HAC validation, mortality reviews and external quality reporting. Exposure to risk adjustment concepts (HCC, SOI/ROM). Experience communicating with providers.: Preferred

Licenses/Certifications:

RN OR LPN OR RHIT OR CCS, or equivalent: Required
Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner Certificate (DIP): within 12 months of hire
Current licensed RN, medical provider or equivalent: Required

Essential Functions:

Performs chart reviews of inpatient medical records following established criteria and checklists. Identifies documentation gaps and flag cases requiring clarification. Drafts provider queries using approved templates when clarification is needed.
Assists with case reviews to support coding accuracy for quality measures. Works with CDI & coding professionals and quality teams as directed. Helps track documentation issues that may impact quality reporting.
Communicates with physicians and clinical staff regarding documentation clarification requests. Provides real-time feedback and education to clinicians on documentation best practices. Serves as a liaison between quality, coding, and clinical teams to resolve documentation issues.
Assists with educational materials and resources on documentation best practices. Supports CDI staff with training preparation as needed.
Stays current on CDI best practices and apply learnings to daily work. Participates in audits and metrics tracking as assigned. Supports continuous improvement efforts within the quality program.
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.

Pay Range: The estimated base pay for this position is $46.75 to $64.13. Additional individual compensation may be available for this role 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. Please contact our Talent Acquisition team for more information.

About the Company

Adventist Health

Faith-based nonprofit integrated health system

Adventist Health is a faith-based nonprofit health system with more than 400 sites of care, including 26 acute care hospitals, primarily on the West Coast and in Hawaii. It provides a full range of health services—from primary and specialty care to hospital-based treatments and wellness programs—delivered across an integrated network of clinics, hospitals, and care facilities. Revenue comes from patient services, insurance reimbursements, and government programs, and earnings are reinvested back into communities to improve health outcomes and expand access to care. The organization differentiates itself through its nonprofit, faith-based model and by reinvesting earnings into community health, along with its broad, integrated network that covers preventive, primary, specialty, and acute care. Its goal is to improve health outcomes for the communities it serves and to expand access to high-quality care.

Company size: 10,001+
Company stage: Grant
Total funding: $210K
Headquarters: Roseville, CA
Founded: Not listed

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