Inpatient CDI Specialist: Elevate Documentation & Coding

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

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.