Clinical Documentation Specialist – SOI/ROM Expert

OhioHealth Corporation; United States; Remote; USD 75,000 - 110,000; Full time

Job summary

OhioHealth is seeking a Clinical Documentation Specialist to review inpatient records and optimize documentation for accurate SOI and ROM metrics. The role partners with physicians and HIM staff to ensure precise DRG assignment and compliant coding within the EHR.

Candidates should hold an RN license in Ohio, a bachelor's degree, and at least five years in adult inpatient settings. Strong communication, collaboration, and problem-solving skills are essential for success in a high reliability

Qualifications

• Bachelor's Degree and RN license (Ohio) required.
• Minimum 5 years in adult inpatient medical/surgical or critical care setting.
• Strong communication and collaboration skills with physicians and HIM staff.

Responsibilities

• Reviews inpatient records to reflect SOI and ROM; maximize ROM, SOI, and revenue.
• Communicates with providers to request clarification; escalate unresolved queries.
• Shows expert knowledge of clinical documentation, coding guidelines, DRG assignment, and ICD-10 documentation.
• Collaborates with HIM coding staff to ensure accurate reflection of SOI/ROM and provider care; escalate discrepancies.
• Assists in education of providers and departments with CDI materials and online courses.

Skills

Critical thinking

Communication skills

Collaboration

Education

Bachelor's Degree

RN license Ohio Board of Nursing

Tools

Microsoft Word

Excel

EHR systems

Job description

OhioHealth is seeking a Clinical Documentation Specialist to review inpatient records and optimize documentation for accurate SOI and ROM metrics. The role partners with physicians and HIM staff to ensure precise DRG assignment and compliant coding within the EHR.

Candidates should hold an RN license in Ohio, a bachelor's degree, and at least five years in adult inpatient settings. Strong communication, collaboration, and problem-solving skills are essential for success in a high reliability