Clinical Documentation Specialist — CDI & Coding Accuracy Expert

University of Maryland Medical System; Largo (MD); On-site; USD 70,000 - 90,000; Full time

Job summary

The University of Maryland Medical System in Largo is seeking a Clinical Documentation Specialist (CDS) to enhance the accuracy of inpatient medical records. You'll ensure precise coding and thorough documentation following guidelines set by ACDIS and AHIMA.

This role involves chart reviews, collaboration with healthcare providers, and the creation of educational resources to support compliance and documentation quality. Candidates must have a relevant degree and healthcare licensure.

Qualifications

• Minimum of 2 years as a Clinical Documentation Integrity Specialist or related roles.
• Strong background in acute care with chart abstraction experience.
• Registered Nurse, Physician, PA, or CRNP licensure is required.

Responsibilities

• Perform concurrent and retrospective chart reviews for accurate documentation.
• Communicate with providers to validate and improve documentation.
• Develop educational materials for accurate medical record documentation.
• Act as a liaison between HIM/coding staff and providers.
• Pursue continuing education to maintain credentials.

Skills

Clinical analysis

Communication skills

Critical thinking

Knowledge of HIM Standards

Education

Associate’s Degree

Job description

The University of Maryland Medical System in Largo is seeking a Clinical Documentation Specialist (CDS) to enhance the accuracy of inpatient medical records. You'll ensure precise coding and thorough documentation following guidelines set by ACDIS and AHIMA.

This role involves chart reviews, collaboration with healthcare providers, and the creation of educational resources to support compliance and documentation quality. Candidates must have a relevant degree and healthcare licensure.