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Clinical Documentation Specialist

University of Maryland Medical System
Full-time
On-site
Largo, Maryland, United States
$38.67 - $58.05 USD yearly
Registered Nurse

Company Description

When you come to the University of Maryland St. Joseph Medical Center, you’re coming to more than simply a beautiful 37-acre, 218-bed suburban Baltimore, Maryland campus. You’re embarking on a professional journey that encourages opportunities, values a team atmosphere, and makes convenience and flexibility a priority. Joining our team of healthcare professionals means you’ll be contributing to a locally and nationally recognized institution. UM St. Joseph has been recognized by The Leapfrog Group as a grade ‘A’ hospital and by U.S. News & World Report as #3 in both the state and Baltimore Metro area, making UM St. Joseph the highest-ranking community hospital in Maryland. In addition, we’ve been consistently recognized as a top employer by Baltimore magazine. 

Job Description

  1. 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.
  2. 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.

Qualifications

  • 4 year / Bachelor’s Degree: Nursing (required)
  • Master’s Degree (preferred)
  • Registered Nurse Certified (required)
  • RHIA, RHIT (preferred)
  • 4 - 6 years Clinical Nursing, or Health Information Management experience (required)
  • 6 - 9 years Clinical Nursing, or Health Information Management experience (preferred)
  • Required Skills: Strong Verbal Communications Skills, Basic Computer skill

Additional Information

All your information will be kept confidential according to EEO guidelines.

Compensation:
Pay Range: $38.67-$58.05
Other Compensation (if applicable):
Review the 2025-2026 UMMS Benefits Guide

Like many employers, UMMS is being targeted by cybercriminals impersonating our recruiters and offering fake job opportunities. We will never ask for banking details, personal identification, or payment via email or text. If you suspect fraud, please contact us at [email protected].

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