HIM Clinical Documentation Specialist

We are seeking a detail-oriented and analytical HIM Clinical Documentation Specialist to join our team in Linthicum United 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 organizations 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 :

• Bachelors 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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Remote Work :

No

Employment Type :

Full-time