Registered Nurse – Clinical Documentation Specialist

TriHealth•Cincinnati, OH

About The Position

Join TriHealth as a Clinical Documentation Specialist and partner with interdisciplinary teams to improve documentation accuracy, support quality outcomes, and elevate patient care. Work Hours: Full time w/benefits 64 hours biweekly, day shift No weekend and holiday rotation Job Overview: Concurrently review inpatient medical records for accuracy and completeness of documentation on admission and throughout hospitalization. Ensure the accuracy and completeness of clinical information within the chart by analyzing for potential gaps in physician documentation through clarifications to improve documentation on principal diagnosis, co-morbidities, present on admission and quality core measures. Facilitate improvement in clinical documentation through education and extensive interaction with physicians, nursing staff and all other members of the health care team. Systematic development and implementation of educational opportunities for physicians, nursing staff and all other members of the health care team. Collaboration with coding staff in assuring complete and compliant documentation in all inpatient charts at time of discharge. Participates in the interdisciplinary process to ensure that selected clinical quality indicators are met. Nurses are at the heart of patient care, and we are proud to have such amazing nurses here at TriHealth. As the region’s leading health system, we are focused on consistency in the patient experience and standardizing nursing care across the system with proven best practices. We aim to continue leading research supporting the evolution of nursing care, especially as TriHealth works to adapt the population health model system-wide. In order to lead these changes, TriHealth must invest in our nurses, which is why we provide multiple opportunities for nurses to achieve their professional development goals through tuition reimbursement programs, specialty certifications and several other continuing education opportunities. Our registered nurses support TriHealth in many different aspects of nursing, including patient care, care coordination, education and management. If you’re interested in joining our world-class nursing team, you can see all current nursing opportunities here on TriHealth.com. I am honored to lead our TriHealth nursing team, and welcome you to join us!

Requirements

Bachelor's degree in nursing. Equivalent experience accepted in lieu of degree
Active valid Registered Nurse (RN) license in the state of Ohio.
Basic Life Support for Healthcare Providers (BLS)
5-7 years' experience Clinical in Nursing
Basic knowledge of keyboarding and Microsoft office

Responsibilities

Facilitates the accurate representation of the severity of illness on TriHealth hospital records by performing admission/continued stay reviews using Clinical Documentation guidelines and standard performance measures.
Processes discharges by updating the Documentation Worksheet to reflect any changes in status, procedures/treatments, and conferring with the physician to finalize diagnoses.
Accurately documents data into CDMP Trak.
Reviews clinical issues with coding staff to assign a working DRG and to resolve discrepancies.
Educates all internal customers on compliant documentation opportunities, coding and reimbursement issues. This standard includes formal presentations at physician meetings nursing and other staff meetings.
Improves documented compliance of selected clinical quality indicators and problems present on admission.