Clinical Documentation Specialist (Level I, II, III)

Requisition #: 314865
Location: Howard County General Hospital, Columbia, MD 21044
Category: Nursing
Work Shift: Day Shift
Work Week: Full Time (40 hours)
Weekend Work Required: No
Date Posted: Dec. 23, 2020

Clinical Documentation Specialist level I:

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. Obtains appropriate documentation through interactions with physicians and staff.

Education:

Requires successful completion of an accredited RN program: BSN, or requires successful completion of an AMA approved Physician Assistant program or 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).

Required Licensure Certification, etc.

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 (AHIMA) and be a Certified Coding Specialist (CCS).

Work Experience:

RN: Requires a minimum of 3 years Registered Nurse clinical experience in similarly complex acute care setting.

PA: Requires a minimum of 3 years Physician Assistant experience in a similarly complex acute care setting.

RHIT/RHIA: Requires minimum of 3 years with acute inpatient coding experience.

Clinical Documentation Specialist level II:

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. Obtains appropriate documentation through interactions with physicians and staff. Develop and maintain provider engagement. Responsible for overall efficiency and effectiveness of the service lines assigned. Interacts with CDI educator on quarterly content development and service line education as needed.

Education:

Requires successful completion of an accredited RN program: BSN, or requires successful completion of an AMA approved Physician Assistant program or 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).

Required Licensure Certification, etc.

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.

Work Experience:

RN: 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 preferred

PA: 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 preferred

RHIT/RHIA: Requires minimum of 3 years with acute inpatient coding experience. Minimum of 2 years as a Clinical Documentation Specialist preferred

Clinical Documentation Specialist level III:

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.

Education:

Requires successful completion of an accredited RN program: BSN, or requires successful completion of an AMA approved Physician Assistant program or 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).

Required Licensure Certification, etc.

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).

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

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

RHIT/RHIA: Requires minimum of 3 years with acute inpatient coding experience. Minimum of 5 years as a Clinical Documentation Specialist preferred

Full Time (40 hours), Exempt

Day Shift, 8:00 am to 4:30 pm

Work Location: Howard County General Hospital, 5755 Cedar Lane, Columbia, MD 21044

Working Conditions: Works in normal office environment where there is little discomfort to due to the extremes of heat, dust, noise, temperature and the like

Johns Hopkins is a Smoke-Free Campus.

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

Johns Hopkins Health System and its affiliates are an Equal Opportunity / Affirmative Action employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.