Clinical Documentation Specialist II

Remote Full-time
Clinical Documentation Specialist | Special Projects | 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.

Position Details
• Shift: Full-Time, Day Shift (40 hours/week) - Monday - Friday
• Location: Fully Remote

Education:

Requires successful completion of:
• Baccalaureate degree, or associates degree, or diploma in nursing from an accredited school of Nursing OR
• Successful completion of an AMA approved Physician Assistant program, OR
• Successful completion of the academic requirements of 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)

Require Licensure Certification, etc.:
• Required to maintain the certification as a Certified Clinical Documentation Specialist (CCDS via ACDIS) or Certified Documentation Integrity Practitioner (CDIP via AHIMA
• RN/APRN: 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.
• PA: 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.
• 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.

What awaits you!
• Medical, Dental, Vision Insurance
• 403B Savings Plan w/employer contribution
• Paid Time off & Paid holidays
• Employee and Dependent Tuition assistance benefits
• Free Parking
• Refer a friend to Johns Hopkins, opportunity to earn $$$
• Health & Wellness programs and more!

For additional inquiries regarding this position, email: [email protected]

Salary Range: Minimum 41.70/hour - Maximum 68.85/hour. Compensation will be commensurate with equity and experience for roles of similar scope and responsibility. In cases where the range is displayed as a $0 amount, salary discussions will occur during candidate screening calls, before any subsequent compensation discussion is held between the candidate and any hiring authority.

We are committed to creating a welcoming and inclusive environment, where we embrace and celebrate our differences, where all employees feel valued, contribute to our mission of serving the community, and engage in equitable healthcare delivery and workforce practices.

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

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