HIM Clin Doc Spec
- Full-Time
- Baltimore, MD
- University Of Maryland Medical System
- Posted 2 years ago – Accepting applications
Job Description
What You Will Do:
The Clinical Documentation Specialist is responsible for the assessment of the quality of clinical documentation for all types ofpatients.
What You Need to Be Successful:
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.
Apply to this Job
The Clinical Documentation Specialist is responsible for the assessment of the quality of clinical documentation for all types ofpatients.
- The Clinical Documentation Specialist shall play a key role in the development of documentation improvement in a multi disciplinaryenvironment to ensure that appropriate coding is utilized for accurate billing purposes.
- DOCUMENTATION: Facilitates initial assessment of the quality of clinical documentation for all types of patients.
- Reviews relevant sections of the record and develops a documentation improvement plan consistent with the clinical picture of eachpatient.
- TEAMWORK: Engages in face-to-face time with physicians; describes what documentation is necessary for accurate coding; explains benefitsof accurate/timely clinical documentation.
- Provides leadership and facilitates multidisciplinary discussions regarding documentation improvement.
- Assists in correcting knowledge deficits on part of physicians and other staff members.
- Assumes a leadership role in continual assessment of the quality of documentation and identifies opportunities for improvement.
- Organizes and participates in training and CDI program promotional activities for physicians and staff.
What You Need to Be Successful:
Education / Certification / Licensure / Registration / Experience 4 year / Bachelor's Degree:
- Nursing (required); Master's Degree (preferred).
- Registered Nurse Certified (required); RHIA, RHIT (preferred).
- 4-6 years Clinical Nursing, or Health Information Management experience (require);
- 6 - 9 years. •Clinical Nursing, or Health Information Management experience (preferred).
- Strong verbal communication and basic computer skills.
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.