Facility Outpatient Clinical Documentation Specialist
TriHealthJoin TriHealth as a Facility Outpatient Clinical Documentation Specialist!!!
At TriHealth, you’ll be part of a mission‑driven health system that empowers you to make a meaningful impact on clinical quality, documentation integrity, and revenue accuracy across outpatient services. In this role, you’ll collaborate closely with clinicians, leaders, and operational teams to strengthen documentation practices, optimize charge capture, and support compliant, high‑quality patient care. Your expertise will directly influence organizational performance while allowing you to lead education, process improvement, and system‑wide initiatives.
TriHealth is consistently recognized as one of the region’s top employers, offering a supportive culture, strong leadership engagement, and opportunities for professional growth. You’ll work within a collaborative environment that values innovation, continuous learning, and the contributions of experienced professionals. With robust benefits, a commitment to work‑life balance, and a focus on employee well‑being, TriHealth provides a workplace where you can thrive and advance your career.
Apply today and grow your career with a team that truly values you.
Location:
Work from Home
Work Schedule:
Full-Time (80 hours bi-weekly)
Day Shift
No Weekend, Holiday or On Call Commitment
Benefits:
TriHealth offers a comprehensive benefits package - including medical, dental, vision, paid time off, retirement plans, and tuition reimbursement. Please view our benefits page https://careers.trihealth.com/what-we-offer/benefits
Job Requirements:
Bachelor’s Degree
Registered Nurse or Licensed Practical Nurse, or Registered Health Information Administrator, or Registered Health Information Technician, ACDIS - Association of Clinical Documentation Integrity Specialists credential, or Certified Professional Coder, Certified Outpatient Coder, Or Certified Documentation Expert Outpatient
General understanding of hospital-based outpatient charging, coding, and/or revenue capture functions
Knowledge of APC and OPPS reimbursement structures (preferred).
Strong project management skills.
Strong interpersonal skills, with demonstrated success at communicating effectively with all levels of the organization, especially senior leadership and department heads.
Skilled ability and comfort with electronic medical records (EPIC preferred), and hospital billing functions.
Proficient with personal computer applications (Excel, Word, and Power Point).
Effective organizational skills with the ability to prioritize and manage multiple functions and responsibilities simultaneously.
Ability to organize and work with minimum supervision at a high level of motivation and initiative while being entrepreneurial, creative and results oriented and must possess proactive orientation with a willingness to take managed risks.
Strong problem solving and investigative skills.
5-7 years’ experience of healthcare knowledge typically obtained from experience as a clinical caregiver or manager, coding specialist, and/or a revenue integrity team member.
Job Overview:
The Facility Outpatient Clinical Documentation Specialist (CDS) is responsible for activities which assist the organization with processes for complete and accurate capture of documentation and charges in a compliant manner for the outpatient services rendered. The Outpatient CDS assists clinical areas to understand relationship of documentation, medical necessity, coding and charging for all services provided to the highest specificity. The Outpatient CDS provides education and training of staff related to these areas of oversight as well as coordinates with clinicians and providers for ongoing education. The CDS will also coordinate process mapping including information systems flowcharts, revenue capture responsibilities, and charge analysts’ functions.
Job Responsibilities:
Regularly conduct chart reviews of clinical departments to review documentation and charge accuracy to integrate into educational sessions with the clinical departments and medical staff.
Performs shadowing and coaching with key stakeholders in the clinical departments to facilitate adoption of best practices, document flow and improve documentation and charging accuracy.
Performs revenue optimization functions including:
Review of accounts for potential missing documentation, coding and charging
Identify root cause of missing charges
Educate Clinical and Ancillary Departments
Perform process improvement activities aimed at revenue optimization
Coordinate with the Clinical Departments, Coding, CDM, and other key stakeholders to address and resolve root cause issues
Analyzes patient clinical and billing data and conducts chart reviews to identify documentation, coding, and charging opportunities.
Summarizes findings, prepares reporting and feedback for clinical departments and finance teams, and supports greater understanding and ownership of documentation and charge accuracy based on claim accuracy results.
Coordinates projects to build upon documentation improvement and charge capture processes for identified areas of opportunity.
Develops and maintains project plans and project tracking, including documentation of project meetings and project issues lists.
Maintains current knowledge of applicable regulatory standards, which may impact utilization of processes and systems.
Other Job-Related Information:
Working Conditions:
Bending - Rarely
Climbing - Rarely
Concentrating – Frequently
Hearing: Conversation – Consistently
Hearing: Other Sounds - Occasionally
Interpersonal Communication - Frequently
Kneeling - Rarely
Lifting <10 Lbs. Occasionally
Lifting 50+ Lbs. - Rarely
Lifting <50 Lbs. - Rarely
Pulling - Rarely
Pushing - Rarely
Reaching - Rarely
Sitting - Consistently
Standing - Occasionally
Stooping – Rarely
Talking - Consistently
Use of Hands - Consistently
Color Vision - Frequently
Visual Acuity: Far - Occasionally
Visual Acuity: Near - Consistently
Walking - Occasionally
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