Our pre-employment assessment is changing as of 10/29. If you are applying to newly posted positions, you will need to take the revised assessment.

Job Details

Clinical Documentation Specialist

Requisition #: 190762
Location: Johns Hopkins Hospital/Johns Hopkins Health System, Baltimore, MD 21201
Category: Allied Health/Clinical Professional
Work Shift: Day Shift
Work Week: Full Time (40 hours)
Weekend Work Required: No
Date Posted: Aug. 13, 2019

Johns Hopkins Health System employs more than 20,000 people annually. When joining the Johns Hopkins Health System, you became part of a diverse organization dedicated to its patients, their families, and the community we serve, as well as to our employees. Career opportunities are available in academic and community hospital settings, home care services, physician practices, international affiliate locations and in the health insurance industry. Great careers continually advance here.

Position Summary:

Facilitates the improvement in the overall quality and completeness of concurrent medical record documentation to help achieve accurate inpatient coding, APR-DRG assignment and severity and risk of mortality levels. Obtains appropriate documentation through interactions with physicians and staff.

Clinical Documentation Specialist I:

This is an entry-level position for newly trained Clinical Documentation Specialists

Clinical Documentation Improvement Specialist is responsible for, but not limited to:

Medical record review:

- Assigning a working APR-DRG and severity level using coding rules and guidelines with follow up reviews as required by LOS standards

- Identification of physician query opportunity

Collaboration with professional inpatient coding professionals

Reconciliation of assigned cases

Accuracy in reporting of CDI program metrics:

- Coverage rate

- Physician query rate

- Query response rate

- Query agreement rate

- Case Mix Index change

- Quality outcomes

- Impact/benefits resulting from physician query.


Requires excellent and comprehensive knowledge of anatomy, physiology, as defined by the Medical Diagnostic Categories and all body systems. Strong background knowledge of disease process, pharmacology.

Requires college-level knowledge of Medical Terminology.

Requires a complete and thorough understanding of the unique functions of each clinical area.

Must be conversant in: ICD-10-CM, APRDRGs, DRGs

Requires knowledge in the use of Microsoft Word, Excel, and Power Point. Knowledge of Access, knowledge of other programming languages a plus.

Requires in-depth knowledge of clinical coding processing and documentation standards, guidelines, policies and procedures.

Must be conversant in clinical documentation improvement.

High level of proficiency in adult education and training

Requires a thorough understanding of Hospital bylaws and Joint Commission standards related to departmental activities.

Requires knowledge of clinical pertinence requirements and proficiency in abstraction and data entry into all of the database systems used for clinical documentation.

Must be able to read and interpret electronic and manual documentation generated by healthcare professionals.

Requires understanding of HSCRC, Maryland Quality Improvement Programs and CMI impact on hospital budget.


Requires successful completion of an accredited program:

a) Requires Baccalaureate degree, or associate degree, or diploma in nursing from an accredited School of Nursing, OR

b) Requires successful completion of an AMA approved Physician Assistant program, OR

c) requires successful completion of the academic requirements or Health Information Technician - RHIT or Registered Health Information Administrator - RHIA certification accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM).

Work Experience:

RN: Requires a minimum of 3 years Registered Nurse clinical experience in similarly complex acute care setting.

PA: Requires a minimum of 3 years Physician Assistant experience in a similarly complex acute care setting.

RHIT/RHIA: Requires minimum of 3 years with acute inpatient coding experience..


Day Shift, Full time (40 hours)

8:00 am – 4:30 pm


Work Location:

JHH, 600 N. Wolfe Street


Strong interpersonal, communication (verbal, non-verbal, and listening) skills.

An understanding of adult learning theory, instructional design and critical thinking

Competent computer skills including word processing, spreadsheets, presentation software.

Required Licensure, Certification:

RN: Must possess current licensure to practice as RN in State of Maryland or another state that participates in the Nurse Licensure Compact.

PA: Must possess current licensure to practice as a PA by the Maryland Board of Physicians. Board certified by the National Commission on Certification of Physician Assistants (NCCPA).

RHIT/RHIA: Must possess certification through the American Health Information Management Association (AHIMA) and be a Certified Coding Specialist (CCS).

Working Conditions:

Requires ability to climb stairs and use step stools to reach top shelves of files at height of over 5 ft. tall.

Requires ability to maneuver in a confined space of not more than 40 in. wide.

Requires ability to lift charts weighing up to 15 lbs.

Requires ability to push a cart full of charts weighing up to 50 lbs.

Possible eye strain from viewing a computer screen.

Requires manual dexterity for data entry.

Requires ability to sit, sand and/or walk for long periods of time.

Requires ability to carry a laptop weighing up to 7 lbs.

Johns Hopkins is a Smoke – Free campus.

Johns Hopkins Health System and its affiliates are drug-free workplace employers.

Johns Hopkins Health System and its affiliates are an Equal Opportunity / Affirmative Action employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.


Learn More About
Johns Hopkins Medicine.