Clinical Documentation Specialist — Elevate Care Quality

System Support; Dayton (OH); On-site; USD 75,000 - 110,000; Full time

Job summary

Premier Health is seeking a Clinical Documentation Specialist at Miami Valley Hospital in Dayton to enhance documentation accuracy and coding integrity. You will collaborate with physicians and care teams to capture severity of illness and ensure compliant documentation that supports appropriate DRG assignments.

The role emphasizes guidance to clinicians, ongoing education, and performance improvement aligned with HIPAA and regulatory standards.

Qualifications

• Bachelor’s degree (BSN) required.
• Bachelor of Science in Nursing, Health Information Management, or equivalent medical degree preferred.
• Area of study in Nursing, HIM, or as a medical college graduate.

Responsibilities

• Analyze clinical documentation for assigned patients and make recommendations for appropriate DRG assignment.
• Facilitate appropriate clinical documentation to support accurate diagnosis coding and ensure the level of service rendered is fully recorded.
• Complete admission reviews with the most appropriate principal diagnosis, complicating conditions, and supporting documentation to reflect severity of illness in compliance with government regulations.
• Identify opportunities for documentation clarification and complete clinically based queries.
• Perform timely follow-up on outstanding queries and document outcomes appropriately.
• Collaborate with physicians, nursing teams, and coding professionals to promote high-quality documentation.

Skills

Critical thinking

Analytical skills

Interpersonal skills

Communication

Teamwork

Education

Bachelor’s degree (BSN) required

BSN, HIM, or equivalent medical degree preferred

Area of study in Nursing, HIM, or medical college graduate

Tools

EPIC

3M

Midas

CDE One

ICD-10 coding

Job description

Premier Health is seeking a Clinical Documentation Specialist at Miami Valley Hospital in Dayton to enhance documentation accuracy and coding integrity. You will collaborate with physicians and care teams to capture severity of illness and ensure compliant documentation that supports appropriate DRG assignments.

The role emphasizes guidance to clinicians, ongoing education, and performance improvement aligned with HIPAA and regulatory standards.