Clinical Documentation Specialist

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

📋 Description

• Execute concurrent assessments of selected patient records to evaluate legibility, clarity, completeness, consistency, and accuracy of clinical documentation.

• Ensure that documentation accurately mirrors the severity of illness, risk of mortality, and services rendered.

• Act as a resource for proper clinical documentation practices.

• Communicate any discrepancies in documentation and coding definitions to physicians through both written and verbal means.

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

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

• Maintain detailed records of completed reviews, queries, and physician responses utilizing computer systems.

• Engage in performance improvement initiatives, in-service training programs, staff meetings, and committees as required.

• Foster a culture of workplace safety, relationship-driven care, professional development, and organizational integrity.

• Carry out additional duties as assigned.

⛳️ Requirements

• A minimum of an Associate/Diploma Degree in Nursing, Health Information Technology (HIT), an advanced nursing degree (NP/APN), or qualifications as a Physician Assistant is required.

• If lacking a college degree, candidates must have three or more years of experience as an inpatient coder or clinical documentation specialist.

• Certifications such as RHIA, RHIT, CCDS, CDIP, or CCS may be accepted in place of RN qualifications.

• Preferred experience includes Critical Care, Medical or Surgical Inpatient Care Nursing as an RN, or roles as a physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), or inpatient coder.

• Availability to work four hours a day, five days a week, from Monday to Friday.

• Must meet population-specific and departmental competencies.

• Proficiency in utilizing computer systems effectively and maintaining records of reviews, queries, and physician responses is essential.

🏝️ Benefits

• Competitive compensation and benefits package, inclusive of medical, dental, and vision coverage starting from day one.

• Retirement savings plan with an employer match beginning on day one.

• Generous paid time off programs.

• Employee recognition initiatives.

• Tuition and professional development reimbursement.

• Assistance with relocation (subject to geographic and position restrictions).

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

• Employee Referral Rewards program.

• Mount Carmel provides DailyPay - if you are hired as an eligible colleague, you will have the ability to track your earnings daily and transfer funds at any time before payday.

• Opportunity to join Diversity, Equity, and Inclusion Colleague Resource Groups.