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MedStar Georgetown University Hospital has been ranked by U.S. News & World Report as a "high performing" hospital for cancer, diabetes and endocrinology, geriatrics, gynecology, nephrology, neurology and neurosurgery, orthopedics, pulmonology and urology.

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Job #32939
Clinical Documentation Specialist
Quality Improvement
Full Time, Days
3800 Reservoir Road, NW, Washington, DC 20007
The Clinical Documentation Specialist (CDS) focuses on the accuracy, completeness and consistency of inpatient clinical documentation to support coding and reporting of high-quality healthcare data. The CDS performs concurrent clinical documentation chart reviews to ensure the medical record appropriately describes the patient's severity of illness and risk of mortality. The CDS develops compliant physician queries guided by the American Health Information Management Association's (AHIMA) "Ethical Standards for Clinical Documentation Improvement Professionals." In addition, the CDS may review medical records retrospectively, in accordance with the hospital's CDI Policies and Procedures, to identify whether or not the physician responded to a query placed concurrently. These functions are performed in accordance with all applicable laws and regulations and MedStar Georgetown University Hospital's philosophy, policies, procedures, and standards.

Required Education/Training:
  • Bachelor of Science degree in a related field; BSN degree preferred.
  • RN preferred.
  • Clinical Documentation Specialist credential (CDIP or CCDS) preferred.
  • Must become AHIMA or ACDIS-certified in CDI within 24 months of becoming eligible for the exam.

Required Experience:
  • Three years of experience in a tertiary hospital.
  • Fundamental knowledge of ICD-9 Official Coding Guidelines and DRG Reimbursement Systems preferred.

Special Knowledge/Skills/Abilities:
  • Effective interpersonal communication skills to interact with all levels of hospital personnel, including medical staff.
  • Demonstrates effective written and verbal communication skills.
  • Demonstrates critical thinking skills and strong clinical knowledge.
  • Is proficient in the use of computers to perform daily work, including Microsoft Office (Word, Excel, PowerPoint, etc.), Outlook, and other applications necessary to perform the CDS role, such as an encoder or CDI workflow and reporting tool.
  • Ability to collect and analyze data related to the CDI program.
MedStar Georgetown University Hospital is an Equal Opportunity Employer and is committed to equal opportunity for all candidates for employment and employees.
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