Clinical Documentation Specialist: Elevate Care & Compliance

Premier Health Partners; Dayton (OH); On-site; USD 70,000 - 90,000; Full time

Job summary

Premier Health Partners, Miami Valley Hospital in Dayton, OH, seeks a Clinical Documentation Specialist. You will ensure records reflect illness severity, procedures, and care quality, supporting compliant documentation and accurate coding to improve patient outcomes.

Work includes collaborating with physicians, nursing teams, and coders to address documentation gaps and drive CDI initiatives. BSN and OH license required; CCDS/CCS preferred.

Qualifications

• Bachelor’s degree is required.
• Active nursing license in Ohio or reciprocal state.
• 3–5 years of CDI or related experience required.
• CCDS or CCS certification preferred.
• Knowledge of ICD-10 coding is preferred.
• Proficiency with EPIC and coding systems.

Responsibilities

• Analyze clinical documentation to support accurate DRG assignments.
• Identify documentation gaps and initiate clinically based queries.
• Perform admission reviews with appropriate diagnoses.
• Educate providers on CDI best practices and coding expectations.
• Collaborate with physicians, nurses, and coding staff to improve documentation quality.
• Complete post-discharge reviews and monitor outcomes.

Skills

Critical thinking

Analytical skills

Interpersonal skills

Communication

Multi-tasking

Teamwork

Problem solving

Confidentiality

HIPAA knowledge

Organizational skills

Clinical documentation

Education

Bachelor’s degree (BSN)

BSN or health information management degree preferred

Area of study in Nursing or HIM

Tools

EPIC

3M

Midas

CDE One

ICD-10 coding knowledge

Job description

Premier Health Partners, Miami Valley Hospital in Dayton, OH, seeks a Clinical Documentation Specialist. You will ensure records reflect illness severity, procedures, and care quality, supporting compliant documentation and accurate coding to improve patient outcomes.

Work includes collaborating with physicians, nursing teams, and coders to address documentation gaps and drive CDI initiatives. BSN and OH license required; CCDS/CCS preferred.