Clinical Documentation Specialist

Johns Hopkins Medicine • Baltimore, MD

2d • $34 - $56 • Remote

About The Position

The Clinical Documentation Specialist (CDS) facilitates the improvement in the overall quality and completeness of concurrent medical record documentation to help achieve accurate inpatient coding, APR-DRG assignment and severity and risk of mortality levels. This role obtains appropriate documentation through interactions with physicians and staff. In this role, the CDS is responsible for medical record review, collaboration with professional inpatient coding professionals, reconciliations of assigned cases and the accurate reporting of CDI program metrics. Additional responsibilities as assigned. This role reports to the Manager

Requirements

• Requires successful completion of: Baccalaureate degree, or associates degree, or diploma in nursing from an accredited school of Nursing OR Successful completion of an AMA approved Physician Assistant program, OR Successful completion of the academic requirements of Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) certification accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM )
• RN/APRN: Must possess a current RN compact (multi-state) license in the state in which you reside. If your state or the Johns Hopkins Health System location in which you are assigned does not participate in the Nurse Licensure compact, an RN license for that state in which you are assigned will be required.
• PA: Must possess current licensure to practice as a Physician Assistant (PA) in the state in which you reside and be board-certified by the National Commission on Certification of Physician Assistants (NCCPA). If your state of the Johns Hopkins Health System location in which you are assigned does not participate in the PA Licensure Compact, a license for the state in which you are assigned will be required.
• RHIT.RHIA: Requires successful completion of the academic requirements for the Registered Health Information Technician (RHIT) certification or Registered Health Information Administrator (RHIA) certification accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) and be a Certified Coding Specialist (CCS).
• Registered Nurse (RN) : RN: Requires a minimum of 3 years Registered Nurse clinical experience in similarly complex acute care setting. In lieu of complex acute care experience, a minimum of 3 years of CDI experience, and /or other relevant clinical experience may be considered
• Physician Assistant (PA) : Requires a minimum of 3 years Physician Assistant experience in a similarly complex acute care setting. In lieu of complex acute care experience, a minimum of 3 years of CDI experience, and /or other relevant clinical experience may be considered.
• RHIT/RHIA : RHIT/RHIA: Requires minimum of 3 years with acute inpatient coding experience. In lieu of acute inpatient coding experience, a minimum of 3 years of CDI experience, and /or relevant clinical experience may be considered.

Nice To Haves

• CCDS certification highly preferred.

Responsibilities

• Medical record review
• Collaboration with professional inpatient coding professionals
• Reconciliations of assigned cases
• Accurate reporting of CDI program metrics
• Additional responsibilities as assigned

Benefits

• Medical, Dental, Vision Insurance
• 403B Savings Plan w/employer contribution
• Paid Time off & Paid holidays
• Employee and Dependent Tuition assistance benefits
• Free Parking
• Refer a friend to Johns Hopkins, opportunity to earn $$$
• Health & Wellness programs and more!

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level