HIM Clinical Documentation Specialist

Job Description

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.

Company Description

The University of Maryland Medical System is a 14-hospital system with academic, community and specialty medical services reaching every part of Maryland and beyond. UMMS is a national and regional referral center for trauma, cancer care, Neurocare, cardiac care, women's and children's health and physical rehabilitation. UMMS is the fourth largest private employer in the Baltimore metropolitan area and one of the top 20 employers in the state of Maryland. No organization will give you the clinical variety, the support, or the opportunities for professional growth that you'll enjoy as a member of our team.

Qualifications

Education

• Highschool Diploma or Equivalent

Licensure

• Registered Nurse (RN); Physician (MD); Physician Assistant (PA), Certified Registered Nurse Practitioner (CRNP); Registered Health Information Technician (RHIT); Registered Health Information Administrator (RHIA); Certified Clinical Documentation Specialist (CCDS) via ACDIS; or a Certified Documentation Integrity Practitioner (CDIP) via AHIMA

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

or

• 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 6 months of eligibility.

Additional Information

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