Clinical Documentation Specialist

University of Maryland Medical System • Largo, MD

9d • $39 - $58

About The Position

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. This role is based out of UM Capital Region Medical Center 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 each patient. TEAMWORK: Engages in face-to-face time with physicians; describes what documentation is necessary for accurate coding; explains benefits of 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.

Requirements

• 4 year / Bachelor’s Degree: Nursing (required)
• Registered Nurse Certified (required)
• 4 - 6 years Clinical Nursing, or Health Information Management experience (required)
• Strong Verbal Communications Skills
• Basic Computer skill

Nice To Haves

• Master’s Degree (preferred)
• RHIA, RHIT (preferred)
• 6 - 9 years Clinical Nursing, or Health Information Management experience (preferred)

Responsibilities

• 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 each patient.
• Engages in face-to-face time with physicians; describes what documentation is necessary for accurate coding; explains benefits of 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 This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 1,001-5,000 employees