Top 56 Clinical documentation specialist 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
University of Maryland Medical System —Bel Air, MD
- $38.67 - $58.05 an hour
- Full-time
- Nursing
- Senior level
- Associate's degree
Clinical Documentation Integrity Specialist
Luminis Health —Annapolis, MD
- $93,120 - $136,344 a year
- Full-time
- RN License
- 5 years
- Computer literacy
- AD&D insurance
- Paid holidays
3d
Senior Consultant - Clinical Documentation Specialist
Deloitte —Baltimore, MD
- $110,700 - $218,300 a year
- Full-time
- Microsoft Word
- Nursing
- RN License
Clinical Data Specialist IV
Johns Hopkins Health System —Baltimore, MD
- Full-time
- Anatomy knowledge
- HIPAA
- Research
- Flexible schedule
12d
Release of Information Specialist III
Johns Hopkins Health System —Baltimore, MD
- Full-time
- Hospital
- HIPAA
- Mid-level
9h
Utilization Management Specialist II
University of Maryland Medical System —Baltimore, MD
- Full-time
- RN License
- Mid-level
- Analysis skills
Senior Outpatient Coding Specialist, Remote
University of Maryland Medical System —Baltimore, MD
- $28.41 - $40.35 an hour
- Part-time
- Remote
- Surgery
- High school diploma or GED
- Senior level
RN Informatics Specialist
Mercy Medical Center —Baltimore, MD
- $45.22 - $81.40 an hour
- Full-time
- Nursing
- RN License
- Hospital
- 403(b) matching
- Paid holidays
Coding Specialist II, Remote Day
University of Maryland Medical System —Linthicum Heights, MD
- Full-time
- Remote
- Customer service
- Mid-level
- 3 years
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
12d
Senior Outpatient Coding Specialist, FT Remote
University of Maryland Medical System —Baltimore, MD
- Full-time
- Remote
- Anatomy knowledge
- Surgery
- Customer service
Electronic Health Record Specialist
Aspire Living & Learning —Bel Air, MD
- $50,000 - $65,000 a year
- Hybrid work
- Nursing
- Microsoft Excel
- Microsoft Outlook
- 403(b) matching
- Health savings account
Quick Apply
16h
Sr Inpatient Coder, FT Remote
University of Maryland Medical System —Baltimore, MD
- Full-time
- Remote
- Customer service
- Computer literacy
- Analysis skills
Practice Development Specialist (Clinical Background)
OneOncology —Owings Mills, MD
- $75,000 - $95,000 a year
- Full-time
- Background check
- Up to 50% travel
- Customer service
Quick Apply
6d
Medical 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
12d
Oncology Data Specialist
University of Maryland Medical System —Towson, MD
- Full-time
- Hybrid work
- Microsoft Word
- Microsoft Excel
- Mid-level
Coding Compliance Auditor Team Lead- Educator
University of Maryland Medical System —Baltimore, MD
- $36.83 - $55.29 an hour
- Full-time
- Surgery
- Customer service
- 5 years
Pediatric 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
12d
ADMINISTRATIVE SPECIALIST II SUPERVISOR
State of Maryland - MDH RICA Baltimore —Baltimore, MD
- $49,214 - $63,669 a year
- Online Application
- Bilingual
- Google Workspace
- Hospital
6h

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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

clinical documentation specialist jobs in baltimore, md

HIM Clinical Document Specialist, UMMC

HIM Clinical Document Specialist, Hybrid

Clinical Documentation Integrity Specialist

Senior Consultant - Clinical Documentation Specialist

Clinical Data Specialist IV

Release of Information Specialist III

Utilization Management Specialist II

Senior Outpatient Coding Specialist, Remote

RN Informatics Specialist

Coding Specialist II, Remote Day

Clinical Coding Specialist

Senior Outpatient Coding Specialist, FT Remote

Electronic Health Record Specialist

Sr Inpatient Coder, FT Remote

Practice Development Specialist (Clinical Background)

Medical Coding Specialist

Oncology Data Specialist

Coding Compliance Auditor Team Lead- Educator

Pediatric Coding Specialist

ADMINISTRATIVE SPECIALIST II SUPERVISOR

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