Clinical Documentation Specialist- RN

TriHealth; Cincinnati (OH); Hybrid; USD 70,000 - 90,000; Full time

Benefits offered by this job

Comprehensive benefits package

Tuition reimbursement

Career growth opportunities

Job summary

TriHealth is seeking a Clinical Documentation Specialist RN to review inpatient records, ensuring accuracy of diagnoses, severity of illness and quality measures. You will educate physicians and nurses, collaborate with coding staff, and drive documentation improvements across the care team.

The role emphasizes clinical analysis, problem solving and cross-team interaction, with remote work options and comprehensive benefits. RN licensure and 5–7 years of clinical experience are required.

Qualifications

• Bachelor’s Degree in Nursing is required.
• Equivalent experience accepted in lieu of degree is preferred.
• 5-7 years of clinical nursing experience is required.
• Basic keyboarding and Microsoft Office proficiency.
• Registered Nurse licensure.

Responsibilities

• Facilitates accurate representation of severity of illness in hospital records.
• Clarifies diagnoses to improve documentation and quality measures.
• Educates physicians, nursing staff and health team on documentation.
• Collaborates with coding staff to ensure complete documentation at discharge.
• Develops and implements educational opportunities for clinical staff.
• Participates in interdisciplinary processes to meet clinical quality indicators.

Skills

Clinical nursing

Documentation analysis

Interpersonal communication

Education

Bachelor’s Degree in Nursing

Equivalent experience accepted

Tools

Microsoft Office

Keyboarding

Job description

Join TriHealth 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.

Location:

Remote

Work Schedule:

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 https://careers.trihealth.com/what-we-offer/benefits

• 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

Job Overview:

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.

Job Responsibilities:

• Facilitates the accurate representation of the severity of illness on TriHealth 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

Working Conditions:

• Bending - Rarely
• Climbing - Rarely
• Concentrating - Frequently
• Continuous Learning - Frequently
• Hearing: Conversation - Consistently
• Hearing: Other Sounds - Occasionally
• Interpersonal Communication - Frequently
• Kneeling - Rarely
• Lifting <10 Lbs. -
• Lifting 50+ Lbs. - Rarely
• Lifting <50 Lbs. - Rarely
• Pulling - Rarely
• Pushing - Rarely
• Reaching - Rarely
• Reading - Frequently
• Sitting - Frequently
• Standing - Rarely
• Stooping - Rarely
• Talking - Consistently
• Thinking/Reasoning - Frequently
• Use of Hands - Consistently
• Color Vision - Frequently
• Visual Acuity: Far - Consistently
• Visual Acuity: Near - Consistently
• Walking - Rarely

TriHealth SERVE Standards and ALWAYS Behaviors

At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following:

• Welcome everyone by making eye contact, greeting with a smile, and saying "hello"
• Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist
• Refrain from using cell phones for personal reasons in public spaces or patient care areas
• Recognize and take personal responsibility to address and recover from service breakdowns when a customer’s expectations have not been met
• Offer patients and guests priority when waiting (lines, elevators)
• Work on improving quality, safety, and service
• Respect cultural and spiritual differences and honor individual preferences.
• Respect everyone’s opinion and contribution, regardless of title/role.
• Speak positively about my team members and other departments in front of patients and guests.
• Value the time of others by striving to be on time, prepared and actively participating.
• Pick up trash, ensuring the physical environment is clean and safe.
• Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.
• Acknowledge wins and frequently thank team members and others for contributions.
• Show courtesy and compassion with customers, team members and the community

• Locations 4452 Eastgate Blvd, Cincinnati, OH, 45245, US