Clinical Documentation Specialist

Job Title

Assisting with ensuring accurate and complete documentation in the medical record to support quality measures and coding accuracy.

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 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.

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. 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.

Job Info

• Job Identification 63114
• Job Category Specialist
• Locations 1 Adventist Health Way, Roseville, CA, 95661, US
• Job Shift Day Shift
• Assignment Category Full-time regular
• 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.