Maryland Licensed Clinical Documentation Specialist

Job Summary

Leading strategic Clinical Documentation Improvement (CDI) initiatives, the full-time Maryland Licensed Clinical Documentation Specialist will enhance the accuracy and compliance of clinical documentation through collaboration with healthcare professionals, conducting chart reviews, and providing staff education, all while working remotely.

Key responsibilities

• Conduct detailed chart reviews and perform clinical validation to identify documentation gaps
• Support documentation improvement efforts and track/report data to measure project success
• Provide education to staff and assist with policy development during high-demand periods

Required qualifications

• Baccalaureate degree, associate degree, or diploma in nursing, or completion of an AMA-approved Physician Assistant program, or academic requirements for RHIT/RHIA certification
• Current certification as a Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP)
• Active RN license, PA license, or relevant RHIT/RHIA certification based on the candidate's qualifications
• Minimum of 3 years of clinical experience in an acute care setting, with preference for 5 years as a Clinical Documentation Specialist
• In lieu of acute care experience, at least 6 years of CDI experience or other relevant clinical experience may be considered