Top 67 Clinical documentation specialist Jobs in Baltimore Md

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
HIM Clinical Document Specialist, UMMC
University of Maryland Medical System —Baltimore, MD
- Full-time
- Medicine
- RN License
- Inpatient
Clinical Coding Specialist
Johns Hopkins Medical Management Corporation —Middle River, MD
- $26 - $30 an hour
- Temporary
- Anatomy knowledge
- Mid-level
- High school diploma or GED
Quick Apply
Registered Nurse Float
Ascension —Baltimore, MD
- $41.12 - $58.79 an hour
- Full-time
- Acute care
- Nursing
- Float pool
- Disability insurance
- Health insurance
Registered Nurse Float
Ascension —Baltimore, MD
- $41.12 - $58.79 an hour
- Full-time
- Acute care
- Nursing
- Float pool
- Disability insurance
- Health insurance
Registered Nurse Cardiac Telemetry
Ascension —Baltimore, MD
- $38.60 - $55.16 an hour
- Part-time
- CPR Certification
- Nursing
- RN License
- Disability insurance
- Health insurance
Registered Nurse Labor and Delivery
Ascension —Baltimore, MD
- $41.12 - $58.79 an hour
- Part-time
- Nursing
- RN License
- Hospital
- Disability insurance
- Health insurance
Registered Nurse
People Encouraging People —Baltimore, MD
- $75,000 - $80,000 a year
- Full-time
- Background check
- Nursing
- RN License
- Mileage reimbursement
- Health insurance
Quick Apply
Registered Nurse IMCU
Ascension —Baltimore, MD
- $41.12 - $58.79 an hour
- Full-time
- CPR Certification
- Nursing
- RN License
- Disability insurance
- Health insurance
Registered Nurse IMCU
Ascension —Baltimore, MD
- $41.12 - $58.79 an hour
- Full-time
- CPR Certification
- Nursing
- RN License
- Disability insurance
- Health insurance
Registered Nurse IMCU
Ascension —Baltimore, MD
- $41.12 - $58.79 an hour
- Full-time
- CPR Certification
- Nursing
- RN License
- Disability insurance
- Health insurance
Registered Nurse Maternal Child Float
Ascension —Baltimore, MD
- $41.12 - $58.79 an hour
- Full-time
- Acute care
- Nursing
- Float pool
- Disability insurance
- Health insurance
Registered Nurse CVPCU
Ascension —Baltimore, MD
- $41.12 - $58.79 an hour
- Full-time
- CPR Certification
- Nursing
- RN License
- Disability insurance
- Health insurance
Registered Nurse Labor and Delivery
Ascension —Baltimore, MD
- $41.12 - $58.79 an hour
- Full-time
- Nursing
- RN License
- Hospital
- Disability insurance
- Health insurance
Registered Nurse ICU
Ascension —Baltimore, MD
- $41.12 - $58.79 an hour
- Full-time
- Nursing
- RN License
- BLS Certification
- Disability insurance
- Health insurance
8d
Registered Nurse CVPCU
Ascension —Baltimore, MD
- $41.12 - $58.79 an hour
- Part-time
- CPR Certification
- Nursing
- RN License
- Disability insurance
- Health insurance
3d
Registered Nurse Cardiac Telemetry
Ascension —Baltimore, MD
- $38.60 - $55.16 an hour
- Full-time
- CPR Certification
- Nursing
- RN License
- Disability insurance
- Health insurance
7d
Registered Nurse Float
Ascension —Baltimore, MD
- $38.60 - $55.16 an hour
- Full-time
- Acute care
- Nursing
- RN License
- Disability insurance
- Health insurance
7d
Registered Nurse Cardiac PCU
Ascension —Baltimore, MD
- $41.12 - $58.79 an hour
- Full-time
- CPR Certification
- Nursing
- RN License
- Disability insurance
- Health insurance
3d
Registered Nurse Float
Ascension —Baltimore, MD
- $38.60 - $55.16 an hour
- Full-time
- Acute care
- Nursing
- RN License
- Disability insurance
- Health insurance

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HIM Clinical Document Specialist, Hybrid

University of Maryland Medical System -
Bel Air, MD

Apply Now

Job Details

Full-time
$38.67 - $58.05 an hour

Qualifications

Inpatient experience
Acute care facility experience
Retrospective medical coding audits
Health record chart audits
Data interpretation
Clinical documentation improvement
Health information management
Clinical documentation standards
Medical record review for billing accuracy

Full Job Description

Job Requirements

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.

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

Work Experience

Required

Associate’s Degree
Registered Nurse (RN), Physician (MD), Physician Assistant (PA), Certified Registered Nurse Practitioner (CRNP)
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 or Minimum of 3 years chart abstraction/chart review experience
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.

Preferred

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).

Additional Information

All your information will be kept confidential according to EEO guidelines.

Compensation:

Pay Range: $38.67 - $58.05

Other Compensation (if applicable): Shift Differentials

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Refine Your Search

clinical documentation specialist jobs in baltimore md

HIM Clinical Document Specialist, Hybrid

HIM Clinical Document Specialist, UMMC

Clinical Coding Specialist

Registered Nurse Float

Registered Nurse Float

Registered Nurse Cardiac Telemetry

Registered Nurse Labor and Delivery

Registered Nurse

Registered Nurse IMCU

Registered Nurse IMCU

Registered Nurse IMCU

Registered Nurse Maternal Child Float

Registered Nurse CVPCU

Registered Nurse Labor and Delivery

Registered Nurse ICU

Registered Nurse CVPCU

Registered Nurse Cardiac Telemetry

Registered Nurse Float

Registered Nurse Cardiac PCU

Registered Nurse Float

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