Clinical Documentation Specialist

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Job ID: 54916
Area of Interest: Nursing
Location: Baltimore, MD US
Hours of Work: M-F
Job Facility: U of M Rehabilitation & Orthopaedic Institute
Employment Type: Full Time
Shift: DAY
What You Will Do:

Full-time Clinical Documentation Specialist Opportunity
***Remote Capability After Training Period***

The Clinical Documentation Specialist (CDS) focuses on the accuracy, completeness and consistency of inpatient clinical documentation to support coding and reporting of high-quality healthcare data.  The CDS concurrently reviews the patient’s medical record in an effort to precisely describe the patient’s severity of illness and risk of mortality in order to clearly reflect accurate outcome and quality data for the hospital, as well as physician profile data.  In addition, the CDS may review medical records retrospectively, if needed and according to the Hospital’s CDI Policies and Procedures, to identify whether or not the physician responded to a query placed concurrently.

  • Registered Nurse (RN) with active license to practice in the State of Maryland.
  • 3-5 years of experience with reviewing medical records as a DRG Analyst, Case Management, Utilization Review, or Quality and Outcomes.
  • Effective interpersonal communication skills to interact with all levels of hospital personnel, including medical staff.
  • Demonstrates effective written and verbal communication skills.
  • Demonstrates critical-thinking skills and strong clinical knowledge.
  • Is proficient in the use of computers to perform daily work including Microsoft Office (Word, Excel, PowerPoint, etc.), and other applications necessary to perform the CDS role such as an encoder or CDI workflow and reporting tool.
  • Ability to collect and analyze data related to the CDI program.
  • Is proficient in reviewing medical records and understanding pertinent clinical information.
  • Member of AHIMA or ACDIS is recommended.
  • Demonstrates good public speaking and presentation skills
  • Demonstrated knowledge and ability in the use of applicable personal computer systems and related software. Ability to learn specific HIM software applications.
  • Demonstrated understanding of applicable medical terminology preferred. Ability to learn medical terminology required.
  • Ability to operate routine office equipment such as photocopy and fax machines, PC’s and peripherals.
  • Effective oral communication skills are necessary to interact and work with various levels of hospital staff in a courteous and effective manner.


What You Need to Be Successful:

  • Registered Nurse (RN) with active license to practice in the State of Maryland.
  • 3-5 years of experience with reviewing medical records as a DRG Analyst, Case Management, Utilization Review, or Quality and Outcomes.
  • Effective interpersonal communication skills to interact with all levels of hospital personnel, including medical staff.
  • Demonstrates effective written and verbal communication skills.
  • Demonstrates critical-thinking skills and strong clinical knowledge.
  • Is proficient in the use of computers to perform daily work including Microsoft Office (Word, Excel, PowerPoint, etc.), and other applications necessary to perform the CDS role such as an encoder or CDI workflow and reporting tool.
  • Ability to collect and analyze data related to the CDI program.
  • Is proficient in reviewing medical records and understanding pertinent clinical information.
  • Member of AHIMA or ACDIS is recommended.
  • Demonstrates good public speaking and presentation skills
  • Demonstrated knowledge and ability in the use of applicable personal computer systems and related software. Ability to learn specific HIM software applications.
  • Demonstrated understanding of applicable medical terminology preferred. Ability to learn medical terminology required.
  • Ability to operate routine office equipment such as photocopy and fax machines, PC’s and peripherals.
  • Effective oral communication skills are necessary to interact and work with various levels of hospital staff in a courteous and effective manner.

We are an Equal Opportunity/Affirmative Action employer.  All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law. 
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