Clinical Documentation Specialist - Nursing

Avita Health System; Ontario (OH); On-site; USD 70,000 - 100,000; Full time

Benefits offered by this job

Competitive wages

Comprehensive benefits

Paid time off

403(b) retirement plan with employer-m

Parental leave

Employee pharmacy discounts

Free on-site parking

Professional growth opportunities

DAISY Nursing Award

Job summary

Avita Health System is seeking a Clinical Documentation Specialist for the Ontario location. The role focuses on improving the quality and completeness of provider-based clinical documentation within the medical records department.

You will work with treating providers to ensure documentation reflects illness severity and services rendered, while coordinating with physicians, case managers, and HIM staff to support accurate reimbursement.

Qualifications

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

Responsibilities

• Improve quality and completeness of provider-based clinical documentation in the medical record.
• Collaborate with treating providers to ensure documentation reflects illness severity and services rendered.
• Interact with physicians, case managers, and HIM coding staff to ensure accurate reimbursement and reporting outcomes.
• Monitor program results and report to Manager and Director.

Skills

ICD10 coding

CPT coding

HCPCS coding

Medical terminology

Anatomy & physiology

Education

RN license (Ohio)

Tools

CDI certification knowledge

Job description

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.

Why Join the Avita Health System Team?

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.

What You Can Expect at Avita:

• A collaborative and engaged workplace culture
• Competitive wages and comprehensive benefits
• Generous paid time off (PTO) to support work-life balance
• 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 and internal advancement
• Recognition programs, including the DAISY Nursing Award for excellence

Join a team that values your contributions and supports your career journey every step of the way.

Avita Health System is an Equal Opportunity Employer.