Top 5 Cdip Jobs in Washington, Dc

HIM Clinical Document Specialist, UM Cap
University of Maryland Medical System —Largo, MD
- Full-time
- Medicine
- RN License
- Senior level
12d
Senior Consultant - Clinical Documentation Specialist
Deloitte —Washington, DC
- $110,700 - $218,300 a year
- Full-time
- Microsoft Word
- Nursing
- RN License
CLINICAL DOCUMENTATION IMPROVEMENT SPECIALIST/CDIS (ON-SITE)
LTSi - Laredo Technical Services, Inc. —Bethesda, MD
- $34 - $37 an hour
- 8 hour shift
- 5 years
- Research
- Mid-level
- Paid holidays
- Dental insurance
Quick Apply
Manager, Clinical Documentation Integrity
Adventist HealthCare —Gaithersburg, MD
- $105,664.42 - $158,496.00 a year
- Full-time
- Medicine
- Anatomy knowledge
- RN License
- Free parking
- AD&D insurance
Quick Apply

More jobs to discover

Find similar jobs that you might be interested in.

Senior Consultant - Clinical Documentation Specialist
Deloitte —Washington, DC
Current Registered Nurse (RN) license required. Strategic Risk: Helping clients to embrace their most significant regulatory, clinical documentation, and…
$110,700 - $218,300 a year
Senior Inpatient Coder, Full Time
University of Maryland Medical System —Baltimore, MD
Serves as a clinical coding subject matter expert, and utilizes critical thinking to analyze and evaluate documentation issues with consultation from the…
$30.26 - $42.37 an hour

I want to receive the latest job alert for cdip in washington, dc

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

cdip jobs near washington, dc

Clinical Documentation Specialist jobs in Washington, DC

Clinical Documentation Improvement Specialist jobs in Gaithersburg, MD

Nursing Clinical Instructor jobs in St. Louis, MO

Remote Charge Capture Specialist jobs in Remote

Clinical Pharmacist jobs in Atlanta, GA

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 Research Coordinator jobs in Stanford, CA

Clinical Documentation Specialist jobs in Massachusetts

Parent Peer Specialist jobs in Wisconsin

Clinical Documentation Specialist jobs in Walter Reed Army Medical Center, DC

Clinical Documentation Specialist jobs in Pomona, CA

Remote Clinical Documentation Specialist jobs in Pennsylvania

Clinical Documentation Specialist jobs in Shawnee, KS

Clinical Documentation Specialist jobs in Cypress, TX

Clinical Documentation Improvement Specialist jobs in Boston, MA

Clinical Documentation Improvement Specialist jobs in Troy, MI

HIM Clinical Document Specialist, UM Cap

University of Maryland Medical System -
Largo, MD

Apply Now

Job Details

Full-time
12 days ago

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

cdip jobs in washington, dc

HIM Clinical Document Specialist, UM Cap

Senior Consultant - Clinical Documentation Specialist

CLINICAL DOCUMENTATION IMPROVEMENT SPECIALIST/CDIS (ON-SITE)

Manager, Clinical Documentation Integrity

More jobs to discover

I want to receive the latest job alert for cdip in washington, dc

Explore jobs in more locations

Job Seeker Tools

Employer Tools

Browse

Stay Connected