A Clinical Documentation Specialist works with information technology systems and applications in health care organizations. Assists clinicians and staff with technology and implementing new systems. Creates systems for organizing and interpreting data and information for clinical trials. Records and manages clinical information about patients, including health assessments and diagnoses, test results, treatments, and follow up care requirements. Reviews and maintains patient records.
Clinical Documentation Integrity Educator Johns Hopkins Health System - 3.8 Baltimore, MD Job Details Full-time 14 hours ago Benefits Health insurance Opportunities for advancement Retirement plan Qualifications Bachelor's degree Clinical documentation Clinical documentation improvement Acute care experience Full Job Description Requisition #: 675858
Location:
Johns Hopkins Health System, Baltimore, MD 21201
Category:
Nursing Schedule:
Day Shift Employment Type:
Full Time Make it Happen at Hopkins | Join our Team! Full-Time | 40 hrs. /week | Day Shifts The Clinical Documentation Integrity Educator is responsible for providing education and training to clinical documentation specialists, coders, compliance auditors, quality improvement staff, physicians, and advanced practice providers on effective and compliant clinical documentation practices. Develops, maintains, and administers a formal Clinical Documentation Integrity (CDI) orientation program for onboarding new hires and applies teaching or learning principles to establish an overall educational program related to effective clinical documentation. Monitors compliant documentation improvement and coding practices, acts as a resource to the CDI team and clinical providers on optimal clinical documentation.
Essential Job Functions:
Provide formal education and ongoing training to physicians, advanced practice providers, and Clinical Documentation Integrity (CDI) staff. Develop and maintain documentation tools, resources, and educational materials to support accurate and complete clinical documentation. Conduct formal physician education sessions at least semi-annually and provide ongoing one-on-one education and coaching to physicians and advanced practice providers. Monitor changes in coding guidelines, regulations, and industry standards and assess their impact on clinical documentation and coding practices. Research clinical advancements and translate findings into practical education for clinicians regarding documentation requirements and for coding professionals regarding appropriate code interpretation and application. Collaborate with physicians and advanced practice providers on a chart-by-chart basis during concurrent documentation reviews. Facilitate appropriate provider clarification when additional or more specific clinical documentation is needed. Promote the quality, accuracy, specificity, and completeness of clinical documentation through evidence-based knowledge, critical analysis, and comprehensive chart review. Demonstrate excellent written and verbal communication skills with the ability to effectively engage and collaborate with clinical and coding professionals as well as physicians. Demonstrate strong organizational and time-management skills with the ability to manage multiple priorities effectively. Deliver clear, engaging, and professional presentations to both small and large audiences.
Required Education, Licensure and Certification:
5+ years of experience in validation or quality assessment, coding and clinical documentation in an acute hospital environment (Required) Certification as a Certified Clinical Documentation Specialist (CCDS via ACDIS) or Certified Documentation Integrity Practitioner (CDIP via AHIMA) required. AND Bachelor's degree in appropriate field of study and one of the credentials:
RN:
Must possess current compact MD and DC RN licensures to practice as
RN PA:
Must possess current licensure to practice as a
PA RHIA / RHIT
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'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 benefits that support you at every stage of your life and career. Retirement plans with employer contributions to help you plan confidently for the future. Generous time off so you can unplug, recharge, and enjoy life outside of work. Access to world-class facilities and innovative technology that fuel your curiosity. Endless opportunities to advance your career as part of the Johns Hopkins team.
