Clinical Documentation Specialist (CDI) – Elevate Coding & Care

University of Maryland Medical System; Baltimore (MD); On-site; USD 85,000 - 115,000; Full time

Job summary

The University of Maryland Medical System seeks a Clinical Documentation Specialist (CDS) to improve inpatient documentation for accurate ICD codes and high-quality data. Under Site Manager guidance, you review records, query providers, and support education across departments.

Requirements include RN/MD/PA/CRNP licensure, Associate’s degree, 2–3 years of inpatient chart review, and CCDS/CDIP certification within 2 years. On-site role with opportunities for professional growth.

Qualifications

• Requires licensure as RN, MD, PA or CRNP.
• Experience in inpatient chart review or CDI role preferred.
• Preferred CCDS or CDIP certification within 2 years of hire.

Responsibilities

• Performs concurrent initial chart reviews within 24-48 hours after admission and follow-ups every 1–3 days.
• Validates observations with providers and develops queries per AHIMA standards.
• Educates providers and staff through sessions, materials, and meetings.
• Acts as clinical liaison between HIM/coding and providers to ensure data accuracy.
• Pursues continuing education to stay current in CDI practices.

Education

Associate’s Degree

Job description

The University of Maryland Medical System seeks a Clinical Documentation Specialist (CDS) to improve inpatient documentation for accurate ICD codes and high-quality data. Under Site Manager guidance, you review records, query providers, and support education across departments.

Requirements include RN/MD/PA/CRNP licensure, Associate’s degree, 2–3 years of inpatient chart review, and CCDS/CDIP certification within 2 years. On-site role with opportunities for professional growth.