Registered Nurse – Clinical Documentation Specialist

Overview

Join Tri Health as a Clinical Documentation Specialist and partner with interdisciplinary teams to improve documentation accuracy, support quality outcomes, and elevate patient care.

• Full-time, benefit-eligible
• 64 hours per pay period
• Day shift
• No weekend or holiday rotation required

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

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.

• 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

• 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.

• Facilitates the accurate representation of the severity of illness on Tri Health 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.

• Climbing – Rarely
• Hearing:
  Conversation – Consistently
• Hearing:
  Other Sounds – Consistently
• Kneeling – Occasionally
• Lifting 50+ Lbs. – Rarely
• Lifting