Top 5 Coder Him Inpatient Jobs in Baltimore, MD

HIM Clinical Document Specialist, UMMC
University of Maryland Medical System —Baltimore, MD
- Full-time
- Medicine
- RN License
- Inpatient
HIM Clinical Document Specialist, Hybrid, DTC
University of Maryland Medical System —Baltimore, MD
- $38.67 - $58.05 an hour
- Full-time
- Nursing
- Inpatient
- Senior level
HIM Clinical Document Specialist, BWMC, Hybrid
University of Maryland Medical System —Glen Burnie, MD
- $38.67 - $58.05 an hour
- Full-time
- Nursing
- Senior level
- Associate's degree
HIM Clinical Document Specialist, Hybrid
University of Maryland Medical System —Bel Air, MD
- $38.67 - $58.05 an hour
- Full-time
- Nursing
- Senior level
- Associate's degree
Medical Coder
Luminis Health —Annapolis, MD
- $31.50 - $42.00 an hour
- Full-time
- Customer service
- Computer literacy
- HIPAA
- AD&D insurance
- Paid holidays

Related jobs to explore

Based on your search for Coder Him Inpatient

HIM Clinical Document Specialist, UMMC
University of Maryland Medical System —Baltimore, MD
Collaborates with providers, leadership and teams to assist with the development and implementation of specific tools and educational materials to support…
HIM Clinical Document Specialist, BWMC, Hybrid
University of Maryland Medical System —Glen Burnie, MD
Collaborates with providers, leadership and teams to assist with the development and implementation of specific tools and educational materials to support…
$38.67 - $58.05 an hour

Show more related jobs

Explore jobs in cities nearby

Check out jobs in cities near your current location, Columbus

Medical Records Technician-Medical Coder
US Veterans Health Administration —Columbus, OH
The training program must have led to eligibility for coding certification/certification examination, and the sponsoring academic institution must have been…
$37,992 - $75,803 a year
19h
Supervisor Coding
OhioHealth —Columbus, OH
Bachelor's or Associates degree in health information or related field. Monitors and responds to Peer Review Organization PR o or Medicare Integrity Program MI…
9d

I want to receive the latest job alert for Coder Him Inpatient in Baltimore, MD

By signing in to your account, you agree to SimplyHired's Terms of Service and consent to our Cookie and Privacy Policy.

Explore jobs in more locations

Coder Him Inpatient jobs near Baltimore, MD

Clinical Documentation Specialist jobs in Glen Burnie, MD

Clinical Documentation Specialist jobs in Bel Air, MD

Coding Specialist jobs in Annapolis, MD

Clinical Documentation Specialist jobs in Baltimore, MD

Clinical Documentation Specialist jobs in Livonia, MI

Clinical Documentation Specialist jobs in Rancho Cucamonga, CA

Clinical Research Coordinator jobs in Ann Arbor, MI

Pediatric Clinical Documentation Specialist jobs in Remote

Clinical Pharmacist jobs in Atlanta, GA

Clinical Documentation Specialist jobs in Orange County, CA

Clinical Documentation Specialist jobs in Virginia

Clinical Documentation Specialist jobs in Brooklyn, NY

Nursing Clinical Instructor jobs in St. Louis, MO

Remote Charge Capture Specialist jobs in Remote

Clinical Documentation Specialist jobs in Beverly, MA

Clinical Documentation Specialist jobs in Mississippi

Clinical Documentation Specialist jobs in Irvine, CA

Clinical Documentation Specialist jobs in Puyallup, WA

Clinical Documentation Specialist jobs in San Francisco Bay Area, CA

Clinical Quality Manager jobs in Chicago, IL

HIM Clinical Document Specialist, UMMC

University of Maryland Medical System -
Baltimore, MD

Apply Now

Job Details

Full-time

Qualifications

Inpatient experience

Full Job Description

Job Requirements

Overview

Under the direction of the Site Manager of the Clinical Documentation Integrity (CDI) program, the Clinical Documentation Specialist (CDS) strives to achieve accurate and complete documentation in the inpatient medical record to support precise ICD-10-CM and ICD-10-PCS coding and reporting of high-quality healthcare data. The CDS is guided by the Association of Clinical Documentation Integrity Specialists (ACDIS) “Code of Ethics” and the American Health Information Management Association’s (AHIMA) “Ethical Standards for Clinical Documentation Integrity Professionals” and the Official Guidelines for Coding and Reporting as approved by the Cooperating Parties.

Key Responsibilities

Key Responsibility 1: Performs concurrent initial chart reviews within 24-48 hours after admission with follow-up reviews occurring every 1-3 days, and retrospective chart reviews, when applicable, to accurately assign/capture the APR-DRG, severity of illness (SOI) and risk of mortality (ROM) in order to reflect quality indicators, resource consumption and outcome measures to ensure accurate and complete documentation for final coding and billing. Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in provider documentation.

Key Responsibility 2: Communicates with providers either verbally or through written methodology to validate observations. Develops provider queries, in compliance with organizational and AHIMA standards when documentation in the medical record pertaining to a significant reportable condition or procedure or other reportable data element is conflicting, incomplete or ambiguous. Utilizes a comprehensive and strong clinical skill set, background and experience in acute care, exceptional critical thinking skills and the ability to prioritize and analyze data quickly and accurately in order to decipher complex clinical cases. Adds detail and/or acuity to ambiguous or implied diagnoses. Will verify if a diagnosis was Present on Admission (POA) and establish the clinical significance and suspected etiology of a finding. Works concurrently to ensure documentation of discharge diagnosis (es) and any co-existing comorbidities are a complete reflection of the patient’s clinical status and care. Evaluates medical record documentation using knowledge about HIM Standards of Coding. Monitors work progress and data to strengthen areas of focus. Consistently meets established productivity metrics for record review.

Key Responsibility 3: Identifies opportunities for education based upon query topics or other identified need for accurate, complete and consistent documentation in the medical record. Collaborates with providers, leadership and teams to assist with the development and implementation of specific tools and educational materials to support medical record documentation. Participates in both formal and informal education sessions including presentations, in-services, face-to-face interactions, newsletters, posters, etc. to the medical staff or clinical departments. Attends service line clinical program meetings and CDI meetings as requested. Identifies strategies for sustained work processes that facilitate complete, accurate clinical documentation. Manages initiatives to support accurate case-mix and quality documentation.

Key Responsibility 4: Acts as a clinical liaison between HIM/coding staff and providers. Partners with coding professionals to perform reconciliation, per policy, to ensure accuracy of diagnostic and procedural data in order to validate the CDS Final APR-DRG/ SOI/ROM against the Final Coded APR- DRG/SOI/ROM.

Key Responsibility 5: Seeks continuing education opportunities in order to stay current on CDI matters and/ or to maintain credentials.

Work Experience

Education

Associate’s Degree

Licensure

Registered Nurse (RN), Physician (MD), Physician Assistant (PA), Certified Registered Nurse Practitioner (CRNP)

Experience

Minimum of 2 years of experience reviewing Inpatient medical records as a Clinical Documentation Integrity Specialist, Coder/DRG Analyst with a clinical background, Care Manager, Utilization Review Specialist, or Quality Review Specialist

Minimum of 3 years chart abstraction/chart review experience

Certifications

Must obtain certification as a Certified Clinical Documentation Specialist (CCDS) via ACDIS or a Certified Documentation Integrity Practitioner (CDIP) via AHIMA within 2 years of hire or eligibility.

Employees hired into this role prior to 1/1/2023 who do not meet the licensure requirements will be grandfathered and considered qualified provided they meet the experience and certification requirements.

Preferred

Licensures/Certifications

Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP) at time of Hire
Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA).

Apply Now

Refine Your Search

Coder Him Inpatient jobs in Baltimore, MD

HIM Clinical Document Specialist, UMMC

HIM Clinical Document Specialist, Hybrid, DTC

HIM Clinical Document Specialist, BWMC, Hybrid

HIM Clinical Document Specialist, Hybrid

Medical Coder

Related jobs to explore

Explore jobs in cities nearby

I want to receive the latest job alert for Coder Him Inpatient in Baltimore, MD

Explore jobs in more locations

Job Seeker Tools

Employer Tools

Browse

Stay Connected