Clinical Documentation Specialist - Nursing

Avita Health System

Crestline (OH)

On-site

USD 50,000 - 70,000

Full time

14 days+

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Benefits offered by this job

Competitive wages and comprehensive benefits

Generous paid time off (PTO)

Health, dental, and vision insurance options

403(b) retirement plans with up to 4% employer match

Paid parental leave

Pharmacy discounts for employees

Free on-site parking

Opportunities for professional growth

Recognition programs

Job summary

A healthcare provider in Crestline, Ohio, is seeking a Clinical Documentation Specialist for its Medical Records Department. The role includes improving documentation quality, collaborating with healthcare providers, and ensuring accurate medical records. Required qualifications: RN Nursing License in Ohio, knowledge of ICD10 and CPT coding, and understanding of medical terminology. Preferred qualifications include two years as a CDI specialist and CDI certification. The position offers a supportive workplace culture and competitive benefits.

Qualifications

Current RN Nursing License in the State of Ohio.
Knowledge of ICD10, CPT, and HCPCS coding.
Familiarity with medical terminology, anatomy, and physiology.

Responsibilities

Facilitate improvement in documentation quality.
Collaborate with providers to ensure accurate documentation.
Monitor program results and report to Manager and Director.

Skills

ICD10 coding knowledge

CPT coding knowledge

HCPCS coding knowledge

Medical terminology knowledge

Anatomy knowledge

Physiology knowledge

Education

Current RN Nursing License in the State of Ohio

Job description

Join Our Team at Avita Health System – Avita Ontario Hospital

Avita Health System is proud to serve the communities of Crawford and Richland counties through three hospitals and numerous clinic locations. Over the past few years, we’ve tripled in size, now employing over 2,300 team members and more than 200 physicians and advanced practitioners. Our mission is to deliver high-quality, compassionate care to the people who depend on us.

We’re currently seeking a dedicated Clinical Documentation Specialist to join our Medical Records Department at our Ontario location.

Position Overview

Accountable for facilitating improvement in overall quality and completeness of provider-based clinical documentation in the medical record. Works collaboratively with treating providers to ensure documentation in the medical record accurately reflects severity of illness as well as level of services rendered. Assesses documentation through extensive review of the record and interacts with physicians, case managers, and HIM coding staff to ensure appropriate reimbursement is received and clinical information utilized in profiling and reporting outcomes is accurate. Monitors program results and reports to Manager and Director.

Qualifications

Required:

Current RN Nursing License in the State of Ohio
ICD10, CPT AND HCPCS coding knowledge.
Knowledge of medical terminology, anatomy and physiology.

Preferred Qualifications:

Two years of experience as a CDI specialist in a hospital setting.
CDI certification from an AHIMA- or ACDIS-approved program.

Benefits

At Avita, we’re committed to creating a supportive, inclusive, and empowering environment where every team member plays a vital role in delivering exceptional care to our communities. Whether you're on the front lines or behind the scenes, your work matters here.