Join TriHealth as a Clinical Documentation Specialist and partner with interdisciplinary teams to improve documentation accuracy, support quality outcomes, and elevate patient care.
Work Hours:
Full time w/benefits
64 hours biweekly, day shift
No weekend and holiday rotation
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
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
Nurses are at the heart of patient care, and we are proud to have such amazing nurses here at TriHealth. As the region’s leading health system, we are focused on consistency in the patient experience and standardizing nursing care across the system with proven best practices. We aim to continue leading research supporting the evolution of nursing care, especially as TriHealth works to adapt the population health model system-wide.
In order to lead these changes, TriHealth must invest in our nurses, which is why we provide multiple opportunities for nurses to achieve their professional development goals through tuition reimbursement programs, specialty certifications and several other continuing education opportunities. Our registered nurses support TriHealth in many different aspects of nursing, including patient care, care coordination, education and management.
If you’re interested in joining our world-class nursing team, you can see all current nursing opportunities here on TriHealth.com.
I am honored to lead our TriHealth nursing team, and welcome you to join us!
The mission of TriHealth is to improve the health status of the people we serve. We pursue our mission by providing a full range of health-related services, including prevention, wellness, education and social programs. Through our acute care hospitals, Good Samaritan Hospital, Bethesda North Hospital, Bethesda Butler Hospital, McCullough-Hyde Memorial Hospital, Good Samaritan Hospital at Evendale and Clinton Regional Hospital in Wilmington, as well as over 140 other TriHealth locations, we are accessible for all in our Cincinnati community.
TriHealth is here for you in all phases of your healthcare journey. Our approximately 12,000 team members, 2,000 physicians and 1,600 volunteers are dedicated to delivering personalized, compassionate care to you and your family.
The Clinical Documentation Specialist will review inpatient medical records for accuracy and completeness, ensuring proper documentation throughout hospitalization. They will also facilitate improvements in clinical documentation through education and collaboration with healthcare teams.
Ready to join TriHealth?
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Frequently Asked Questions
What does a Registered Nurse – Clinical Documentation Specialist do at TriHealth?
As a Registered Nurse – Clinical Documentation Specialist at TriHealth, you will: the Clinical Documentation Specialist will review inpatient medical records for accuracy and completeness, ensuring proper documentation throughout hospitalization. They will also facilitate improvements in clinical documentation through education and collaboration with healthcare teams..
Why join TriHealth as a Registered Nurse – Clinical Documentation Specialist?
TriHealth is a leading Hospitals and Health Care company.
Is the Registered Nurse – Clinical Documentation Specialist position at TriHealth remote?
The Registered Nurse – Clinical Documentation Specialist position at TriHealth is based in Cincinnati, Ohio, United States. Contact the company through Clera for specific work arrangement details.
How do I apply for the Registered Nurse – Clinical Documentation Specialist position at TriHealth?
You can apply for the Registered Nurse – Clinical Documentation Specialist position at TriHealth directly through Clera. Click the "Apply Now" button above to start your application. Clera's AI-powered platform will help match your profile with this opportunity and guide you through the application process. You can also learn more about TriHealth on their website.
