Clinical Documentation Specialist

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This position will provide general second-level review support to the Pediatric Units

Full-Time | 40 hrs/week | Day Shifts | Fully Remote

This role focuses on leading and supporting strategic Clinical Documentation Improvement (CDI) initiatives to enhance the accuracy, quality, and compliance of clinical documentation. The position involves collaborating with physicians, nurses, coders, IT, and leadership to identify documentation gaps, implement solutions, and optimize electronic health record (EHR) use.

Key responsibilities include conducting detailed chart reviews, performing clinical validation, supporting documentation improvement efforts, and tracking/reporting data to measure project success. The role also provides education to staff and providers, assists with policy development, and offers coverage during high-demand periods.

Required Education, Licensure and Certifications:

Current and maintain a Certified Clinical Documentation Specialist (CCDS via ACDIS) or Certified Documentation Integrity Practitioner (CDIP via AHIMA) required, AND

• RN/APRN: Bachelor or Associated Degree in Nursing | Must possess a current RN compact (multi-state) license in the state in which you reside. If your state or the Johns Hopkins Health System location in which you are assigned does not participate in the Nurse Licensure compact, an RN license for that state in which you are assigned will be required.  OR

• PA: Successful completion of an AMA approved PA program | Must possess current licensure to practice as a Physician Assistant (PA) in the state in which you reside and be board-certified by the National Commission on Certification of Physician Assistants (NCCPA). If your state of the Johns Hopkins Health System location in which you are assigned does not participate in the PA Licensure Compact, a license for the state in which you are assigned will be  required. OR

• RHIT.RHIA: Requires successful completion of the academic requirements for the Registered Health Information Technician (RHIT) certification or Registered Health Information Administrator (RHIA) certification accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM) and be a Certified Coding Specialist (CCS). 

Work Experience

Registered Nurse (RN):

Requires a minimum of 3 years Registered Nurse clinical experience in similarly complex acute care setting. Minimum of 5 years as a Clinical Documentation Specialist preferred. In lieu of complex acute care experience, at least 6 years of CDI experience and/or other relevant clinical experience may be considered.

Physician Assistant (PA):

Requires a minimum of 3 years Physician Assistant experience in a similarly complex acute care setting.  Minimum of 5 years as a Clinical Documentation Specialist preferred.  In lieu of complex acute care experience, at least 6 years of CDI experience and/or other relevant clinical experience may be considered.

RHIT/RHIA:

Requires minimum of 3 years with acute inpatient coding experience. Minimum of 5 years as a Clinical Documentation Specialist preferred. In lieu of acute inpatient coding, at least 6 years of CDI experience and/or relevant clinical experience may be considered. 

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

For additional inquiries regarding this position, email:  rhaggar3@jh.edu