Clinical Documentation Specialist

Johns Hopkins Medicine; Washington; Remote; USD 62,000 - 103,000; Full time

Job summary

Johns Hopkins Health System seeks a Clinical Documentation Improvement specialist to lead and support CDI initiatives across Pediatric units, ensuring accurate and compliant documentation. Remote day shifts with full-time hours focus on chart reviews, clinical validation, staff education, and policy development.

The role collaborates with physicians, nurses, coders, IT, and leadership to identify gaps and implement EHR optimization strategies, with salary commensurate to experience.

Qualifications

• RN/APRN: Must possess a current RN compact license in the state of residence or a license for the Johns Hopkins location if not in compact.
• PA: Must possess current licensure to practice as PA and board-certified by NCCPA in the state of residence.
• RHIT/RHIA: Requires CAHIIM accreditation and CCS certification.

Responsibilities

• Lead and support CDI initiatives to improve accuracy, quality, and compliance of clinical documentation.
• Conduct detailed chart reviews and clinical validation to identify documentation gaps.
• Provide staff and provider education and assist with policy development.
• Track and report data to measure project success and ensure EHR optimization.
• Cover during high-demand periods as needed.

Education

RN/APRN: Bachelor or Associated Degree in Nursing

PA: AMA approved PA program

RHIT.RHIA: CAHIIM CAHIIM + CCS certification

Job description

Requisition #:675370 Location:Johns Hopkins Health System, Baltimore, MD 21201 Category:Nursing Schedule:Day Shift Employment Type:Full Time

Make it Happen at Hopkins | Join our Team

This position will provide general second-level review support to the Pediatric Units

Full-Time | 40 hrs/week | Day Shifts | Fully Remote

This role focuses on leading and supporting strategic Clinical Documentation Improvement (CDI) initiatives to enhance the accuracy, quality, and compliance of clinical documentation. The position involves collaborating with physicians, nurses, coders, IT, and leadership to identify documentation gaps, implement solutions, and optimize electronic health record (EHR) use.

Key responsibilities include conducting detailed chart reviews, performing clinical validation, supporting documentation improvement efforts, and tracking/reporting data to measure project success. The role also provides education to staff and providers, assists with policy development, and offers coverage during high-demand periods.

Required Education, Licensure And Certifications

• RN/APRN: Bachelor or Associated Degree in Nursing | 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. OR
• PA: Successful completion of an AMA approved PA program | 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. OR
• 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).

Work Experience

Registered Nurse (RN):

Requires a minimum of 3 years Registered Nurse clinical experience in similarly complex acute care setting. Minimum of 5 years as a Clinical Documentation Specialist preferred. In lieu of complex acute care experience, at least 6 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. Minimum of 5 years as a Clinical Documentation Specialist preferred. In lieu of complex acute care experience, at least 6 years of CDI experience and/or other relevant clinical experience may be considered.

Rhit/Rhia

Requires minimum of 3 years with acute inpatient coding experience. Minimum of 5 years as a Clinical Documentation Specialist preferred. In lieu of acute inpatient coding, at least 6 years of CDI experience and/or relevant clinical experience may be considered.

We’re proud to offer a robust benefits package that supports your health, growth, and well-being. Discover our full offerings and costs here: mybenefitsjhhs.com

What Awaits You

• Competitive pay and benefits that support you at every stage of your life and career.
• Retirement plans with employer contributions to help you plan confidently for the future.
• Generous time off so you can unplug, recharge, and enjoy life outside of work.
• Access to world-class facilities and innovative technology that fuel your curiosity.
• Endless opportunities to advance your career as part of the Johns Hopkins team

For additional inquiries regarding this position, email: [e-mail]

Salary Range:

Minimum 45.28/hour - Maximum 74.76/hour. Compensation will be commensurate with equity and experience for roles of similar scope and responsibility. In cases where the range is displayed as a $0 amount, salary discussions will occur during candidate screening calls, before any subsequent compensation discussion is held between the candidate and any hiring authority.

The Hospital reserves the right to modify employee schedules as needed.

We are committed to creating a welcoming and inclusive environment, where we embrace and celebrate our differences, where all employees feel valued, contribute to our mission of serving the community, and engage in equitable healthcare delivery and workforce practices.

Johns Hopkins Health System and its affiliates are drug-free workplace employers.

Johns Hopkins Health System and its affiliates are an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.