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Johns Hopkins Medicine · 2 months ago

Clinical Documentation Specialist

United States

Full-time

Remote

Mid, Senior Level

3+ years exp

Johns Hopkins Medicine is seeking a Clinical Documentation Specialist to improve the quality, accuracy, and compliance of clinical documentation across the healthcare organization. The role involves supporting specialized projects, collaborating with healthcare professionals, conducting reviews of documentation, and providing education to staff.

Health CareHealth DiagnosticsHospitalMedicalTraining

Responsibilities

Supports specialized projects to optimize documentation practices and EHR utilization

Collaborates with physicians, nurses, coders, IT staff, and CDE leadership to identify challenges and implement solutions

Conducts comprehensive reviews of clinical documentation to identify improvement opportunities

Provides education and precepting to staff/providers as needed

Collects, analyzes, and reports data to measure project outcomes and guide future improvements

Offers case review support during peak periods, staff absences, or large-scale events

Assists in developing coding policies and procedures to support workflow efficiency and compliance

Reports directly to the Manager

Qualification

Certified Clinical Documentation SpecialistCertified Documentation Integrity PractitionerClinical Documentation ImprovementRN clinical experienceCoding policies developmentData analysisEducationPreceptingCollaboration skills

Required

Must maintain certification as Certified Clinical Documentation Specialist (CCDS via ACDIS) or Certified Documentation Integrity Practitioner (CDIP via AHIMA)

Current RN compact (multistate) license in state of residence

If compact not available, state-specific RN license required

Current PA license in state of residence

Board-certified by NCCPA

If compact not available, state-specific PA license required

Completion of academic requirements for RHIT or RHIA certification accredited by CAHIIM

Certification as Certified Coding Specialist (CCS) also required

Successful Completion Of One Of The Following Is Required: Nursing: Baccalaureate degree, Associate degree, or diploma in Nursing from an accredited school

Successful Completion Of One Of The Following Is Required: Physician Assistant: AMA-approved Physician Assistant program

Successful Completion Of One Of The Following Is Required: Health Information: Academic requirements for RHIT or RHIA certification accredited by CAHIIM

Minimum 3 years of RN clinical experience in a complex acute care setting

Minimum 3 years PA experience in a complex acute care setting

Minimum 3 years acute inpatient coding experience