Impactful Clinical Documentation Specialist

System Support; Walnut Hills (OH); On-site; USD 75,000 - 98,000; Full time

Job summary

Premier Health is seeking a Clinical Documentation Specialist to improve accuracy and completeness of medical records. You will work with physicians, nursing, and coding teams to ensure documentation reflects severity of illness and services provided.

The role emphasizes CDI best practices, concurrent queries, and collaboration across disciplines to enhance patient outcomes and compliance with regulations.

Qualifications

• Bachelor’s degree or higher required in nursing, HIM, or equivalent medical degree.
• 3–5 years of related experience preferred.
• Certified Clinical Documentation Specialist (CCDS) or Certified Coding Specialist (CCS) preferred.

Responsibilities

• Analyze clinical documentation for assigned patients and recommend appropriate DRG.
• Facilitate accurate clinical documentation to support diagnosis coding and level of service.
• Complete admission reviews with principal diagnosis and supporting documentation per regulations.
• Identify opportunities for documentation clarification and perform queries.
• Educate providers on Clinical Documentation Improvement concepts and collaborate with coding staff.
• Perform post-discharge CDI reviews and support department goals.
• Maintain confidentiality per HIPAA and work toward organizational quality metrics.

Skills

Critical thinking

Problem-solving

Analytical skills

Interpersonal skills

Communication

Teamwork

Education

Bachelor’s degree in Nursing, Health Information Management, or equivalent medical degree

Tools

EPIC

3M

Midas

CDE One

Job description

Premier Health is seeking a Clinical Documentation Specialist to improve accuracy and completeness of medical records. You will work with physicians, nursing, and coding teams to ensure documentation reflects severity of illness and services provided.

The role emphasizes CDI best practices, concurrent queries, and collaboration across disciplines to enhance patient outcomes and compliance with regulations.