Clinical Documentation Specialist- RN

Join Tri Health as a Clinical Documentation Specialist RN and use your clinical nursing expertise in a role that impacts patient care beyond the bedside. You’ll collaborate with physicians, nurses, and coding professionals to ensure inpatient medical records accurately capture each patient’s diagnoses, severity of illness, and quality measures. It’s a great opportunity for an experienced RN who enjoys clinical analysis, education, problem-solving, and working across the healthcare team.

We offer career growth opportunities
, a comprehensive benefits package, and competitive pay based on level of education and experience.

Remote

Full time (40 hours weekly)

In addition to a comprehensive benefits package—including medical, dental, vision, paid time off, retirement plans, and tuition reimbursement, this role offers competitive pay based on education level and experience. Please view our benefits page

• Bachelor’s Degree in Nursing (Required)
• Equivalent experience accepted in lieu of degree (Preferred)
• 5 - 7 years experience Clinical in Nursing (Required)
• Basic keyboarding and Microsoft office
• Registered Nurse

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.

• Facilitates the accurate representation of the severity of illness on Tri Health 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

• Bending
  - Rarely
• Climbing
  - Rarely
• Concentrating
  - Frequently
• Continuous Learning
  - Frequently
• Hearing:
  Conversation
  - Consistently
• Hearing:
  Other Sounds
  - Occasionally
• Interpersonal Communication
  - Frequently
• Kneeling
  - Rarely
• Lifting