HIM Clinical Document Specialist, UMMC

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

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.

Key Responsibilities

• Performs concurrent initial chart reviews within 24–48 hours after admission with follow‑up reviews 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) that 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 through written methodology to validate observations. Develops provider queries in compliance with organizational and AHIMA standards when documentation 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/or 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 diagnosis(es) and any co‑existing comorbidities fully reflect the patient’s clinical status and care. Evaluates medical record documentation using knowledge of HIM Standards of Coding, monitors work progress and data, and consistently meets established productivity metrics for record review.
• Identifies opportunities for education based upon query topics or other identified needs for accurate, complete and consistent documentation in the medical record. Collaborates with providers, leadership and teams to develop and implement specific tools and educational materials to support medical record documentation. Participates in formal and informal education sessions, including presentations, in‑services, face‑to‑face interactions, newsletters and posters, and attends service line clinical program meetings and CDI meetings as requested.
• 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 in order 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 to maintain credentials.

Education

• Associate’s Degree

Licensure

• Registered Nurse (RN), Physician (MD), Physician Assistant (PA), Certified Registered Nurse Practitioner (CRNP)

Experience

• 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.
• Minimum of 3 years chart abstraction/chart review experience.

Certifications

• 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.
• Employees hired into this role prior to 01/01/2023 who do not meet the licensure requirements will be grandfathered and considered qualified provided they meet the experience and certification requirements.

Preferred Licensure/Certifications

• 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).