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. Through extensive review of medical records and interaction with physicians and other healthcare team members, the specialist promotes documentation that is complete, accurate, and sufficient to support code assignment, medical necessity, severity of illness, risk of mortality, and the level of services rendered. The role also provides and supports education on clinical documentation requirements.

This is a part-time position for 20 hours per week, scheduled for four hours per day, five days a week, Monday through Friday. The position conducts concurrent patient record reviews, identifies and communicates documentation discrepancies, supports appropriate coding, and maintains records of completed reviews, queries, and physician responses.

Requirements

• Associate degree or diploma in Nursing or Health Information Technology (HIT), or an advanced degree in nursing (NP/APN) or Physician Assistant.
• In the absence of a college degree, at least 3 years of experience as an inpatient coder or clinical documentation specialist.
• A Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Professional (CDIP), or Certified Coding Specialist (CCS) credential will 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

• Exhibit Mount Carmel Service Excellence Behavior Standards, including friendliness, courtesy, effective communication, professionalism, and accountability.
• Meet population-specific and other competencies required by the department.
• Promote workplace and patient safety by following applicable policies, procedures, and plans.
• Support relationship-based care by helping create a caring, healing environment centered on patients and families.
• 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, and serve as a resource on documentation requirements.
• Communicate documentation discrepancies and coding definitions to physicians verbally and in writing, as needed, in accordance with query standards and policies.
• Conduct one-on-one education sessions with physicians and other healthcare team members about documentation requirements.
• Collaborate with physicians, patient care services, case management, coding specialists, and other healthcare disciplines on documentation issues.
• Use computer systems effectively and maintain records of reviews, queries, and physician response outcomes.
• Participate in performance improvement activities and attend in-service programs and other professional development activities.
• Attend and actively participate in staff meetings and committees as requested.
• Promote organizational integrity by raising questions and promptly reporting actual or potential wrongdoing.
• Perform other duties as assigned.

Benefits

• Competitive compensation and benefits packages, including 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 for eligible colleagues, allowing them to view earnings and transfer money before payday.
• Opportunity to join Diversity, Equity, and Inclusion Colleague Resource Groups.

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level
• Education Level: Associate degree