HIM Clinical Documentation Specialist

Company Description

The University of Maryland Medical System is a 14-hospital system with academic, community and specialty medical services reaching every part of Maryland and beyond. UMMS is a national and regional referral center for trauma, cancer care, Neurocare, cardiac care, women’s and children’s health and physical rehabilitation. UMMS is the fourth largest private employer in the Baltimore metropolitan area and one of the top 20 employers in the state of Maryland. No organization will give you the clinical variety, the support, or the opportunities for professional growth that you’ll enjoy as a member of our team. 

Job Description

We are seeking a detail-oriented and analytical HIM Clinical Documentation Specialist to join our team in Linthicum, United States. In this role, you will play a crucial part in ensuring the accuracy, completeness, and quality of clinical documentation within our healthcare organization.

• Review and analyze clinical documentation to ensure accuracy, completeness, and compliance with coding guidelines and regulatory requirements
• Collaborate with healthcare providers to clarify documentation and improve the quality of patient records
• Identify opportunities for documentation improvement and provide education to clinical staff
• Assist in the development and implementation of clinical documentation improvement initiatives
• Monitor and report on key performance indicators related to documentation quality and accuracy
• Participate in regular audits and quality assurance activities
• Stay up-to-date with changes in coding guidelines, healthcare regulations, and industry best practices
• Support the organization's efforts in maintaining accurate and compliant medical records for optimal patient care and appropriate reimbursement
• Contribute to process improvement initiatives within the Health Information Management department

Qualifications

• Bachelor's degree in Health Information Management, Nursing, or related field
• RHIA, RHIT, CCS, or CDIP certification
• 3-5 years of experience in clinical documentation improvement or related field
• In-depth knowledge of medical terminology and coding systems (e.g., ICD-10, CPT)
• Proficiency in electronic health record (EHR) systems
• Strong understanding of healthcare compliance and regulations, including HIPAA
• Excellent written and verbal communication skills
• Exceptional attention to detail and accuracy
• Analytical mindset with the ability to identify trends and patterns in clinical documentation
• Knowledge of quality metrics and performance improvement methodologies
• Familiarity with clinical workflows and healthcare operations
• Strong organizational skills and ability to manage multiple priorities efficiently
• Demonstrated ability to work collaboratively with healthcare providers and multidisciplinary teams
• Commitment to ongoing professional development and staying current with industry trends

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

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