Maryland Licensed Clinical Documentation Specialist

Job Summary

A company is looking for a Clinical Documentation Improvement Specialist.

Key Responsibilities

• Facilitate modifications to clinical documentation through interaction with physicians and healthcare team members
• Communicate with physicians regarding unclear or conflicting medical record documentation to clarify information and educate on severity identification
• Evaluate daily documentation by the medical staff and provide clinical evaluations of medical records

Required Qualifications

• Three years of clinical acute care nursing experience or completion of Health Records Administration program with three years of relevant experience
• Specific knowledge as a consultant in Medical Record coding and DRG assignment is required
• Prior Clinical Documentation Improvement (CDI) work experience is preferred
• Knowledge of computer technology and quality assurance activities related to DRG is highly preferred
• Relevant licensure or certifications such as CCS, RN, or equivalent required