Clinical Documentation Specialist

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Make It Happen at Hopkins | Join our TEAM!

Full-Time | 40 hrs/week | Day Shift | Fully Remote

The Clinical Documentation Specialist (CDS) facilitates the improvement in the overall quality and completeness of concurrent medical record documentation to help achieve accurate inpatient coding, APR-DRG assignment and severity and risk of mortality levels. This role obtains appropriate documentation through interactions with physicians and staff. In this role, the CDS is responsible for medical record review, collaboration with professional inpatient coding professionals, reconciliations of assigned cases and the accurate reporting of CDI program metrics. Additional responsibilities as assigned. This role reports to the Manager

Required Education, Licensure and Certifications:

Current and maintain a Certified Clinical Documentation Specialist (CCDS via ACDIS) or Certified Documentation Integrity Practitioner (CDIP via AHIMA) required, AND

• RN/APRN: Bachelor or Associated Degree in Nursing | Must possess a current RN compact (multi-state) license in the state in which you reside. If your state or the Johns HopkinsHealth System location in which you are assigned does not participate in the Nurse Licensure compact, an RN license for that state in which you are assigned will be required. OR

• PA: Successful completion of an AMA approved PA program | Must possess current licensure to practice as a Physician Assistant (PA) in the state in which you reside and be board-certified by the National Commission on Certification of Physician Assistants (NCCPA). If your state of the Johns Hopkins Health System location in which you are assigned does not participate in the PA Licensure Compact, a license for the state in which you are assigned will be required. OR

• RHIT/RHIA: Requires successful completion of the academic requirements for the Registered Health Information Technician (RHIT) certification or Registered Health Information Administrator (RHIA) certification accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) and be a Certified Coding Specialist (CCS).

Work Experience

• Registered Nurse (RN):

RN: Requires a minimum of 3 years Registered Nurse clinical experience in similarly complex acute care setting. In lieu of complex acute care experience, a minimum of 3 years of CDI experience, and /or other relevant clinical experience may be considered

• Physician Assistant (PA):

Requires a minimum of 3 years Physician Assistant experience in a similarly complex acute care setting. In lieu of complex acute care experience, a minimum of 3 years of CDI experience, and /or other relevant clinical experience may be considered.

• RHIT/RHIA:

RHIT/RHIA: Requires minimum of 3 years with acute inpatient coding experience. In lieu of acute inpatient coding experience, a minimum of 3 years of CDI experience, and /or relevant clinical experience may be considered.

We're proud to offer a robust benefits package that supports your health, growth, and well-being. Discover our full offerings and costs here: mybenefitsjhhs.com

What Awaits You:

• Competitive pay and benefitsthat support you at every stage of your life and career.
• Retirement plans with employer contributionsto help you plan confidently for the future.
• Generous time offso you can unplug, recharge, and enjoy life outside of work.
• Access to world-class facilities and innovative technologythat fuel your curiosity.
• Endless opportunities to advance your careeras part of the Johns Hopkins team.

For additional inquiries regarding this position, email: rhaggar3@jh.edu