Clinical Documentation Specialist

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🏈 Ohio – Remote

🏈 Ohio – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

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OhioHealth

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1891

🏥 Healthcare

⚕️ Healthcare Insurance

🧘 Wellness

Healthcare • Healthcare Insurance • Wellness

OhioHealth is a not-for-profit healthcare system headquartered in Columbus, Ohio, dedicated to providing exceptional patient care and a wide range of medical services. With facilities spread across multiple locations, OhioHealth offers comprehensive healthcare services including cancer care, maternity, midlife clinics for women, virtual health appointments, and specialized care for transgender and LGBTQ patients. They also focus on patient education with health and wellness classes, support groups, and health quizzes. OhioHealth is committed to improving community health through various community relations and health initiatives. They provide resources such as price transparency, financial assistance, and patient rights information to enhance the healthcare experience for all patients.

📋 Description

• Review inpatient medical records to identify documentation opportunities reflecting severity of illness and risk of mortality • Identify principal and secondary diagnoses, comorbidities, complications, CCs, and MCCs using clinical criteria • Concurrently assign DRGs and capture documentation specificity supporting diagnoses and clinical indicators • Attend multidisciplinary rounds and communicate with providers • Submit verbal, electronic, or written queries requesting clarification or additional documentation • Escalate unanswered queries and communicate with physician advisors • Collaborate with HIM coding staff to ensure accurate clinical documentation and resolve coding discrepancies • Apply clinical documentation requirements, coding guidelines, DRG assignment standards, compliance standards, and ICD-10 requirements • Participate in documentation or query audits and support interdepartmental compliance • Assist with provider and departmental education, including courses, printed materials, and presentations

🎯 Requirements

• Bachelor's Degree in Nursing • Current RN (Registered Nurse) license in the State of Ohio from the Ohio Board of Nursing • Minimum 5 years of experience in an adult inpatient medical/surgical or critical care setting • Critical reasoning skills in clinical decision making and problem solving • Ability to interpret data • Flexible, positive, and clear interpersonal and communication skills • Ability to provide information collaboratively with physicians and other staff • Organization and computer skills • Expert knowledge of clinical documentation requirements, coding guidelines, DRG assignment, and clinical conditions and procedures • Understanding of compliance standards, AHIMA Standards of Ethical Coding guidelines, hospital quality metrics, and healthcare regulations • Competency in ICD-10 documentation requirements • Working knowledge of Microsoft Word, Excel, and facility-based EHR applications

🏖️ Benefits

• Full-time schedule with 40 scheduled weekly hours • Day shift

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