Clinical Documentation Specialist (Remote)

Position Overview

The Clinical Documentation Specialist plays a crucial role in ensuring the accuracy, completeness, and integrity of clinical records. This is achieved through thorough reviews, education, and consultation, supporting appropriate clinical documentation that impacts code assignment, medical necessity, severity of illness, risk of mortality, and levels of care. This position requires regular collaboration with physicians and multidisciplinary healthcare teams to enhance the quality of documentation.

Key Responsibilities

• Adhere to and exemplify service excellence standards by communicating effectively, maintaining professionalism, and fostering a courteous environment.
• Fulfill department-required competencies with attention to population needs.
• Support a Culture of Safety by strictly following policies and procedures to prevent injuries, violence, and adverse events to colleagues and patients.
• Promote relationship-based care focusing on patient-centeredness throughout the healthcare experience.
• Conduct concurrent chart reviews to assess documentation for legibility, clarity, completeness, consistency, and accuracy.
• Ensure clinical documentation accurately reflects severity of illness, risk of mortality, and provided services; serve as a resource for proper clinical documentation standards.
• Communicate any discrepancies or clarifications needed with physicians both verbally and in writing following query guidelines.
• Lead one-on-one educational sessions with providers and other team members to address specific documentation requirements.
• Collaborate across multidisciplinary teams including physicians, nursing, case management, and coding to resolve documentation challenges.
• Effectively use computer systems to track completed reviews, queries, and physician responses.
• Participate in performance improvement initiatives and professional development activities related to care documentation.
• Engage actively in staff meetings and committees as requested.
• Support organizational integrity by promptly reporting potential ethical concerns or wrongdoing.
• Perform additional assigned duties as required.

Minimum Qualifications

• Possession of an Associate/Diploma Degree in Nursing or Health Information Technology (HIT), or an advanced nursing degree such as Nurse Practitioner (NP/APN) or Physician Assistant.
• If no college degree, at least three years of experience as an inpatient coder or clinical documentation specialist is required.
• Alternatively, certifications such as RHIA, RHIT, CCDS, CDIP, or CCS may be accepted in place of an RN license.
• Preferred experience includes critical care, medical, or surgical inpatient nursing, or experience as an inpatient coder.

Benefits and Highlights

• Competitive salary with comprehensive benefits including medical, dental, and vision coverage effective immediately.
• Retirement savings plan with employer matching starting day one.
• Generous paid time off options.
• Employee recognition programs to foster motivation and engagement.
• Tuition and professional development reimbursement opportunities.
• Relocation assistance subject to eligibility criteria.
• Discounted tuition and enrollment at the affiliated College of Nursing.
• Employee referral bonus program.
• Access to DailyPay, enabling early access to earned wages prior to payday.
• Opportunities to participate in Diversity, Equity, and Inclusion resource groups supporting a supportive workplace culture.

Organization Information

Mount Carmel, part of Trinity Health, has been a cornerstone in Central Ohio's healthcare for over 135 years. Serving more than 1.3 million patients annually through multiple hospitals, outpatient and emergency centers, surgery units, specialty and primary care offices, and community outreach programs, Mount Carmel is dedicated to compassionate, person-centered care. The Mount Carmel College of Nursing offers extensive educational programs for nursing professionals. This role provides a meaningful opportunity to join a mission-driven team committed to making a difference in healthcare.

Equal Employment Opportunity

Aligned with its mission and core values, the organization values diversity and inclusivity, respecting the dignity and unique talents of every colleague. All qualified applicants will be considered without discrimination based on race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other protected categories.