Clinical Documentation Specialist - Remote

Trinity Health • Columbus, OH

1d • Remote

About The Position

The Clinical Documentation Specialist uses advanced clinical and coding expertise to support the integrity of clinical documentation as a reviewer, educator, and consultant. Through extensive medical record review and interaction with physicians and other healthcare team members, the specialist promotes documentation that accurately reflects code assignment, medical necessity, severity of illness, risk of mortality, and the level of services provided. The role also participates in developing and delivering education for providers and healthcare team members.

The specialist supports Mount Carmel’s service excellence, safety, relationship-based care, and quality expectations. Responsibilities include concurrent review of selected patient records, identifying and communicating documentation discrepancies, providing documentation guidance, collaborating with a multidisciplinary team, and maintaining records of reviews and queries. The position also contributes to performance improvement and ongoing professional development.

Requirements

• Associate or diploma degree in Nursing or Health Information Technology (HIT), or an advanced degree in nursing (NP/APN) or Physician Assistant; alternatively, in the absence of a college degree, at least 3 years of experience as an inpatient coder or clinical documentation specialist.
• An RHIA, RHIT, CCDS, CDIP, or CCS credential may be considered in lieu of an RN.

Nice To Haves

• Experience in 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.

Responsibilities

• Model Mount Carmel’s Service Excellence Behavior Standards, including friendliness, courtesy, effective communication, professionalism, and first-class service.
• Meet population-specific and other competencies required by the department.
• Promote a culture of safety by following policies, procedures, and plans intended to prevent workplace injury, violence, or adverse outcomes.
• Support relationship-based care by helping create a caring and healing environment centered on patients and families.
• For patient care providers, provide nursing care, ensure patient safety, promote evidence-based practice and quality initiatives, and demonstrate professionalism consistent with the ANCC Magnet Recognition Program model.
• Conduct concurrent reviews of selected patient records for legibility, clarity, completeness, consistency, and precision of clinical documentation.
• Ensure documentation accurately reflects severity of illness, risk of mortality, and services provided; serve as a resource on clinical documentation.
• Communicate documentation discrepancies and coding definitions to physicians verbally and in writing as needed, following query standards and policies.
• Conduct one-to-one education sessions with physicians and other healthcare team members about specific documentation requirements.
• Collaborate with physicians, patient care services, case management, coding specialists, and other healthcare disciplines on clinical documentation issues.
• Use computer systems effectively and maintain records of completed reviews, queries, and physician response outcomes.
• Participate in performance improvement activities and attend in-service programs and other activities to support professional growth and knowledge of care documentation requirements.
• Attend and actively participate in staff meetings and serve on committees as requested.
• Support Organizational Integrity by raising questions and promptly reporting actual or potential wrongdoing.
• Perform other duties as assigned.

Benefits

• Medical, dental, and vision coverage starting on day one.
• Retirement savings account with employer match starting on day one.
• Generous paid time off programs.
• Employee recognition programs.
• Tuition and professional development reimbursement.
• Relocation assistance, subject to geographic and position restrictions.
• Discounted tuition and enrollment opportunities at Mount Carmel College of Nursing.
• Employee Referral Rewards program.
• DailyPay access for eligible colleagues.
• Opportunity to join Diversity, Equity, and Inclusion Colleague Resource Groups.

What This Job Offers

• Job Type: Full-time
• Education Level: Associate degree