HIM Clinical Document Specialist, Hybrid

University of Maryland Medical System; Bel Air (MD); On-site; USD 53,271 - 79,969; Full time

Benefits offered by this job

Shift differentials

Job summary

The University of Maryland Medical System is hiring a Clinical Documentation Specialist in Bel Air, Maryland. This role focuses on ensuring accurate and complete documentation in inpatient medical records to support high-quality healthcare data.

Key responsibilities include performing chart reviews, communicating with healthcare providers, and developing educational tools for effective documentation practices. The position requires at least an Associate's Degree, RN/MD qualifications, and experience in clinical documentation integrity.

Qualifications

• Minimum of 2 years of experience in clinical documentation integrity or chart review.
• Must obtain CCDS or CDIP certification within 2 years of hire.
• Experience as Care Manager or Quality Review Specialist is a plus.

Responsibilities

• Perform concurrent initial chart reviews and ensure accurate documentation.
• Communicate with providers to validate observations and resolve documentation issues.
• Develop educational materials for medical staff on documentation standards.
• Act as a liaison between HIM/coding staff and clinical providers.

Skills

Clinical documentation review

Critical thinking

Communication

Team collaboration

Education

Associate’s Degree

Registered Nurse (RN)

Physician (MD)

Physician Assistant (PA)

Certified Registered Nurse Practitioner (CRNP)

Tools

Medical coding standards

Job description

Job Overview

Under the direction of the Site Manager of the Clinical Documentation Integrity (CDI) program, the Clinical Documentation Specialist (CDS) strives to achieve accurate and complete documentation in the inpatient medical record to support precise ICD-10-CM and ICD-10-PCS coding and reporting of high-quality healthcare data. The CDS is guided by the Association of Clinical Documentation Integrity Specialists (ACDIS) “Code of Ethics” and the American Health Information Management Association’s (AHIMA) “Ethical Standards for Clinical Documentation Integrity Professionals” and the Official Guidelines for Coding and Reporting as approved by the Cooperating Parties.

Responsibilities

• Performs concurrent initial chart reviews within 24-48 hours after admission with follow-up reviews occurring every 1-3 days, and retrospective chart reviews, when applicable, to accurately assign/capture the APR-DRG, severity of illness (SOI) and risk of mortality (ROM) in order to reflect quality indicators, resource consumption and outcome measures to ensure accurate and complete documentation for final coding and billing. Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in provider documentation.
• Communicates with providers verbally or in writing to validate observations. Develops provider queries, in compliance with organizational and AHIMA standards when documentation in the medical record pertaining to a significant reportable condition or procedure or other reportable data element is conflicting, incomplete or ambiguous. Utilizes a comprehensive and strong clinical skill set, background and experience in acute care, exceptional critical thinking skills and the ability to prioritize and analyze data quickly and accurately to decipher complex clinical cases. Adds detail and/acuity to ambiguous or implied diagnoses. Verifies if a diagnosis was Present on Admission (POA) and establishes the clinical significance and suspected etiology of a finding. Works concurrently to ensure documentation of discharge diagnoses and any co-existing comorbidities reflect the patient’s clinical status and care. Evaluates medical record documentation using knowledge of HIM Standards of Coding. Monitors work progress and data to strengthen areas of focus. Consistently meets established productivity metrics for record review.
• Identifies opportunities for education based upon query topics or other identified need for accurate, complete and consistent documentation in the medical record. Collaborates with providers, leadership and teams to assist with the development and implementation of specific tools and educational materials to support medical record documentation. Participates in both formal and informal education sessions including presentations, in-services, face‑to‑face interactions, newsletters, posters, etc. to the medical staff or clinical departments. Attends service line clinical program meetings and CDI meetings as requested. Identifies strategies for sustained work processes that facilitate complete, accurate clinical documentation. Manages initiatives to support accurate case‑mix and quality documentation.
• Acts as a clinical liaison between HIM/coding staff and providers. Partners with coding professionals to perform reconciliation, per policy, to ensure accuracy of diagnostic and procedural data to validate the CDS Final APR‑DRG/SOI/ROM against the Final Coded APR‑DRG/SOI/ROM.
• Seeks continuing education opportunities to stay current on CDI matters and/or to maintain credentials.

Required Qualifications

• Associate’s Degree
• Registered Nurse (RN), Physician (MD), Physician Assistant (PA), Certified Registered Nurse Practitioner (CRNP)
• Minimum of 2 years of experience reviewing inpatient medical records as a Clinical Documentation Integrity Specialist, Coder/DRG Analyst with a clinical background, Care Manager, Utilization Review Specialist, or Quality Review Specialist or minimum of 3 years chart abstraction/chart review experience
• Must obtain certification as a Certified Clinical Documentation Specialist (CCDS) via ACDIS or a Certified Documentation Integrity Practitioner (CDIP) via AHIMA within 2 years of hire or eligibility.

Preferred Qualifications

• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP) at time of hire
• Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA)

Additional Information

All your information will be kept confidential according to EEO guidelines.

Compensation

• Pay Range: $38.67 - $58.05
• Other Compensation (if applicable): Shift Differentials