Clinical Documentation Specialist II

Johns Hopkins Medicine; Baltimore (MD); Remote; USD 58,000 - 95,000; Full time

Benefits offered by this job

Competitive pay

Retirement plans

Generous time off

Access to innovative technology

Career advancement

Job summary

Johns Hopkins Medicine seeks a Clinical Documentation Specialist (CDS) to improve inpatient documentation quality and support accurate coding. The CDS interacts with physicians and staff to obtain documentation, collaborates with CDI and coding teams, and reports CDI metrics.

Requires RN/PA/RHIT/RHIA qualifications and active certifications. The role offers a full-time schedule with a fully remote setup and competitive benefits.

Qualifications

• Current RN license in state of residence.
• PA license in good standing and board-certified (NCCPA).
• RHIT or RHIA CAHIIM certification and CCS credential.

Responsibilities

• Improve documentation quality and completeness for inpatient records.
• Interact with physicians and staff to obtain necessary documentation.
• Collaborate with inpatient coding professionals and CDI team.
• Report CDI program metrics and participate in reconciliations.

Skills

Clinical Documentation

Inpatient coding familiarity

Collaboration

Education

RN license (US)

PA license (US)

RHIT/RHIA CAHIIM cert

Job description

Make It Happen at Hopkins | Join our TEAM!

Position Details

• Shift: Full-Time, Day Shift (40 hours/week) - Monday - Friday
• Location: Fully Remote

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

Education:

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)

Required Licensure and Certification.:

All CDS level II are required to maintain certification as a Certified Clinical Documentation Speciaslist (CCDS via ACDIS) or Certified Documentation Integrity Practitioner (CDIP via AHIMA)

• 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).

Work Experience

• 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.

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

• • 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 $42.33/visit - Maximum $68.88/visit. 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.

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.