Clinical Documentation Specialist I, II or III

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YOU BELONG HERE

What Awaits You?

• Career growth and development
• Employee and Dependent Tuition Assistance
• Diverse and collaborative working environment
• Affordable and comprehensive benefits package

Our competitive Benefit Package is designed to support the well-being and financial security of our employees. You can explore the details of our benefits offering by visiting the following link: https://jhhs.mybenefitsjhhs.com/

Summary:

This position guides, fosters, and supports the effectiveness of Departmental Clinical Documentation Excellence Teams. Responsibilities include: distributing documentation information to respective departments; performing educational outreach to individual units and provider groups along with the CDS assigned to those units; supports training of new staff members; and the design and development of educational tools for staff and Providers. Facilitates the improvement in the overall quality and completeness of concurrent medical record documentation to help achieve accurate inpatient coding, APR-DRG assignment, severity level and reimbursement. Obtains appropriate documentation through interactions with physicians and collaboration with other departments. CDS will continue to show productivity based on average daily reviews and queries (to be approved and determined by the CDE manager). She/he must be very active with physician education regarding CDE, Mortality and MHAC and PSI reviews. Must demonstrate willingness to assist other CDS's with their work flow. A positive attitude is a must.

Education:

Requires successful completion of an accredited program:

a) requires Baccalaureate degree, or associate degree, or diploma in nursing from an accredited School of Nursing, OR

b) requires successful completion of an AMA approved Physician Assistant program, OR

c) requires successful completion of the academic requirements or Health Information Technician - RHIT or Registered Health Information Administrator - RHIA certification accredited by the

Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM).

Work Experience:

RN: Requires a minimum of 3 years Registered Nurse clinical experience in similarly complex acute care setting. Minimum of 5 years as a Clinical Documentation Specialist preferred. In lieu of complex acute care experience, a minimum of 6 years of CDI experience, and /or other relevant clinical experience may be considered.

PA: Requires a minimum of 3 years Physician Assistant experience in a similarly complex acute care setting. Minimum of 5 years as a Clinical Documentation Specialist preferred. In lieu of complex acute care experience, a minimum of 6 years of CDI experience, and /or other relevant clinical experience may be considered.

RHIT/RHIA: Requires minimum of 3 years with acute inpatient coding experience. Minimum of 5 years as a Clinical Documentation Specialist preferred. In lieu of acute inpatient coding experience, a minimum of 6 years of CDI experience, and /or relevant clinical experience may be considered.

Licensure/Certification:

RN: Must possess current licensure to practice as RN in State of Maryland or another state that participates in the Nurse Licensure Compact and must possess clinical documentation certification through the Association of Clinical Documentation Improvement Specialists (ACDIS) and/or American Health Information Management Association(AHIMA)

PA: Must possess current licensure to practice as a PA by the Maryland Board of Physicians. Board certified by the National Commission on Certification of Physician Assistants (NCCPA). Must possess clinical documentation certification through the Association of Clinical Documentation Improvement Specialists (ACDIS) and/or American Health Information Management Association(AHIMA)

RHIT/RHIA: Must possess clinical documentation certification through the Association of Clinical Documentation Improvement Specialists (ACDIS) and/or American Health Information Management Association (AHIMA) and be a Certified Coding Specialist (CCS).

We highly prefer candidates for the Clinical Documentation Specialist III level, but we are also open to considering individuals with less experience for lower-level positions.

Clinical Documentation Specialist II
Clinical Documentation Specialist I

Experience
RN:

PA:

RHIT/RHIA:

RN:

PA:

RHIT/RHIA:

Education

Licensure

RN:

PA:

RHIT/RHIA:

Requires a minimum of 3 years Registered Nurse clinical experience in similarly complex acute care setting. Minimum of 2 years as a Clinical Documentation Specialist required. In lieu of complex acute care experience, a minimum of 3 years of CDI experience, and /or other relevant clinical experience may be considered. Requires a minimum of 3 years Physician Assistant experience in a similarly complex acute care setting. Minimum of 2 years as a Clinical Documentation Specialist required. In lieu of complex acute care experience, a minimum of 3 years of CDI experience, and /or other relevant clinical experience may be considered Requires minimum of 3 years with acute inpatient coding experience. Minimum of 2 years as a Clinical Documentation Specialist required. In lieu of acute inpatient coding experience, a minimum of 4 years of CDI experience, and /or relevant clinical experience may be considered. 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 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 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 Same as level IIISame as level III RN: Must possess current licensure to practice as RN in State of Maryland or another state that participates in the Nurse Licensure Compact.PA: Must possess current licensure to practice as a PA by the Maryland Board of Physicians. Board certified by the National Commission on Certification of Physician Assistants (NCCPA).RHIT/RHIA: Must possess certification through the American Health Information management Association and be a Certified Coding Specialist (CCS).Requires certification as a CCDS/CDIP or must acquire certification within 1 year of advancement to a CDS-II. Must possess current licensure to practice as RN in State of Maryland or another state that participates in the Nurse Licensure Compact. Must possess current licensure to practice as a PA by the Maryland Board of Physicians. Board certified by the National Commission on Certification of Physician Assistants (NCCPA). Must possess certification through the American Health Information Management Association (AHIMA) and be a Certified Coding Specialist (CCS).

JHM prioritizes the health and well-being of every employee. Come be healthy at Hopkins!

Diversity and Inclusion are Johns Hopkins Medicine Core Values. We are committed to creating a welcoming and inclusive environment, where we embrace and celebrate our differences, where all employees feel valued, contribute to our mission of serving the community, and engage in equitable healthcare delivery and workforce practices.

Johns Hopkins Health System and its affiliates are drug-free workplace employers.