Clinical Documentation Specialist Registered Nurse

Join Our Team as a Clinical Documentation Specialist Registered Nurse!

Join TriHealth as a Clinical Documentation Specialist and partner with interdisciplinary teams to improve documentation accuracy, support quality outcomes, and elevate patient care. Apply today and be part of a team that is passionate about making a difference.

We offer career growth opportunities, and a comprehensive benefits package.

Location: 

• Remote

• This position requires in‑person attendance for scheduled onsite meetings; therefore, candidates must be located within the greater Cincinnati area.

Work Schedule: 

• Full time

• 80 hours per pay period

• Day shift

• No weekend or holiday rotation required

Incentives & Benefits: 

We offer a comprehensive benefits package, including medical, dental, vision, paid time off, retirement plans, and tuition reimbursement. 

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

Selection Process:

As part of the selection process, candidates will be required to complete a pre‑employment assessment test. Candidates who successfully pass the assessment may be considered for the next steps in the selection process, including interviews.

Job Requirements:

• Bachelor's degree in nursing.  Equivalent experience accepted in lieu of degree

• Active valid Registered Nurse (RN) license in the state of Ohio. Basic Life Support for Healthcare Providers (BLS)

• 5-7 years' experience Clinical in Nursing (Med-Surg, Tele, or ICU)

• Basic knowledge of keyboarding and Microsoft office 

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:
Climbing - Rarely
Hearing: Conversation - Consistently
Hearing: Other Sounds - Consistently
Kneeling - Occasionally
Lifting 50+ Lbs. - Rarely
Lifting <50 Lbs. - Occasionally
Pulling - Frequently
Pushing - Consistently
Reaching - Frequently
Sitting - Rarely
Standing - Consistently
Stooping - Occasionally
Talking - Consistently
Use of Hands - Consistently
Color Vision - Frequently
Visual Acuity: Far - Consistently
Visual Acuity: Near - Consistently
Walking - Consistently

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: 

Serve: ALWAYS…
• 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
 

Excel: ALWAYS…
• 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: ALWAYS…
• 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: ALWAYS…
• 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.

Engage: ALWAYS…
• Acknowledge wins and frequently thank team members and others for contributions.
• Show courtesy and compassion with customers, team members and the community

Job Keywords: Registered Nurse, Nurse, Clinical Documentation