Clinical Documentation Specialist

This is a fully remote position, open to applicants in Ohio.

📋 Description

• Perform concurrent evaluations of selected patient records to assess legibility, clarity, completeness, consistency, and accuracy of clinical documentation.

• Ensure that clinical documentation accurately represents the severity of illness, risk of mortality, services provided, medical necessity, and the level of services delivered.

• Act as a resource regarding proper clinical documentation practices.

• Communicate discrepancies in documentation and coding definitions to physicians both in writing and verbally.

• Conduct individualized educational sessions with physicians and members of the healthcare team.

• Collaborate with physicians, patient care services, case management, coding specialists, and other healthcare professionals.

• Utilize computer systems and maintain records of completed reviews, queries, and responses from physicians.

• Participate in performance improvement initiatives, in-service training, staff meetings, and committees.

• Foster professional development and understanding of care documentation requirements.

• Advocate for service excellence, workplace safety, relationship-based care, and organizational integrity.

• Perform additional duties as assigned.

⛳️ Requirements

• Must have an Associate/Diploma Degree in Nursing, Health Information Technology (HIT), or an advanced degree in nursing (NP/APN) or as a Physician Assistant.

• In the absence of a college degree, a minimum of 3 years of experience as an inpatient coder or clinical documentation specialist is required.

• RHIA, RHIT, CCDS, CDIP, or CCS certifications will be accepted in lieu of a nursing degree.

• Preferred experience includes Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, Physician Assistant (PA), Nurse Practitioner/Advanced Practice Nurse (NP/APN), or as an inpatient coder.

• Must meet population-specific competencies and all other requirements as outlined by the department.

• A solid understanding of clinical documentation requirements, coding definitions, query standards, and relevant policies is essential.

• Must be proficient in using computer systems and maintaining records of reviews, queries, and physician responses.

🏝️ Benefits

• Competitive compensation and benefits packages, which include medical, dental, and vision coverage starting on day one.

• Retirement savings plan with employer matching contributions beginning on day one.

• Generous paid time off programs.

• Employee recognition initiatives.

• Tuition and professional development reimbursement.

• Relocation assistance (specific geographic and position restrictions apply).

• Discounted tuition and enrollment opportunities at the Mount Carmel College of Nursing.

• Employee Referral Rewards program.

• DailyPay option for eligible employees.

• Diverse, Equity, and Inclusion Colleague Resource Groups.