Clinical Documentation Specialist

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

📋 Description

• Direct initiatives to uphold the integrity of clinical documentation in the roles of reviewer, educator, and consultant.

• Perform concurrent evaluations of chosen patient records to ensure legibility, clarity, completeness, consistency, and accuracy.

• Verify that documentation accurately represents the severity of illness, risk of mortality, medical necessity, and services rendered.

• Act as a resource for appropriate clinical documentation practices.

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

• Facilitate one-on-one educational sessions with physicians and members of the healthcare team.

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

• Effectively utilize computer systems and maintain records of reviews, queries, and responses from physicians.

• Engage in performance improvement activities, in-service programs, staff meetings, and committees.

• Report any actual or potential misconduct and carry out other assigned responsibilities.

⛳️ Requirements

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

• If lacking a college degree, 3 or more years of experience as an inpatient coder or clinical documentation specialist is required.

• RHIA, RHIT, CCDS, CDIP, or CCS certification may be considered in place of an RN.

• Preferred experience in Critical Care, Medical or Surgical Inpatient Care Nursing as an RN, PA, NP/APN, or as an inpatient coder.

• Clinical and coding proficiency.

• Capability to conduct comprehensive medical record reviews.

• Familiarity with clinical documentation standards, coding definitions, query protocols, and policies.

• Strong written and verbal communication skills with physicians and healthcare team members.

• Competence in using computer systems and maintaining review/query documentation.

🏝️ Benefits

• Medical, dental, and vision insurance coverage available from day one.

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

• Generous paid time off policies.

• Employee recognition initiatives.

• Reimbursement for tuition and professional development.

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

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

• Employee Referral Rewards program.

• DailyPay access for eligible employees.

• Diversity, Equity, and Inclusion Colleague Resource Groups.