HIM Clinical Documentation Specialist

University of Maryland Medical System • Glen Burnie, MD

6d • $39 - $58

About The Position

We are seeking a detail-oriented and analytical HIM Clinical Documentation Specialist to join our team in Linthicum, United States. In this role, you will play a crucial part in ensuring the accuracy, completeness, and quality of clinical documentation within our healthcare organization.

Requirements

• Bachelor's degree in Health Information Management, Nursing, or related field
• RHIA, RHIT, CCS, or CDIP certification
• 3-5 years of experience in clinical documentation improvement or related field
• In-depth knowledge of medical terminology and coding systems (e.g., ICD-10, CPT)
• Proficiency in electronic health record (EHR) systems
• Strong understanding of healthcare compliance and regulations, including HIPAA
• Excellent written and verbal communication skills
• Exceptional attention to detail and accuracy
• Analytical mindset with the ability to identify trends and patterns in clinical documentation
• Knowledge of quality metrics and performance improvement methodologies
• Familiarity with clinical workflows and healthcare operations
• Strong organizational skills and ability to manage multiple priorities efficiently
• Demonstrated ability to work collaboratively with healthcare providers and multidisciplinary teams
• Commitment to ongoing professional development and staying current with industry trends

Responsibilities

• Review and analyze clinical documentation to ensure accuracy, completeness, and compliance with coding guidelines and regulatory requirements
• Collaborate with healthcare providers to clarify documentation and improve the quality of patient records
• Identify opportunities for documentation improvement and provide education to clinical staff
• Assist in the development and implementation of clinical documentation improvement initiatives
• Monitor and report on key performance indicators related to documentation quality and accuracy
• Participate in regular audits and quality assurance activities
• Stay up-to-date with changes in coding guidelines, healthcare regulations, and industry best practices
• Support the organization's efforts in maintaining accurate and compliant medical records for optimal patient care and appropriate reimbursement
• Contribute to process improvement initiatives within the Health Information Management department

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 1,001-5,000 employees