[Hiring] Clinical Documentation Specialist @TriHealth

Role Description

Join TriHealth as a Clinical Documentation Specialist RN and use your clinical nursing expertise in a role that impacts patient care beyond the bedside. You’ll collaborate with physicians, nurses, and coding professionals to ensure inpatient medical records accurately capture each patient’s diagnoses, severity of illness, and quality measures. It’s a great opportunity for an experienced RN who enjoys clinical analysis, education, problem-solving, and working across the healthcare team.

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.
• 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.

Qualifications

• Bachelor's Degree in Nursing (Required)
• Equivalent experience accepted in lieu of degree (Preferred)
• 5 - 7 years experience Clinical in Nursing (Required)
• Basic keyboarding and Microsoft Office skills
• Registered Nurse

Requirements

• 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.
• Improves documented compliance of selected clinical quality indicators and problems present on admission.

Benefits

• Comprehensive benefits package, including medical, dental, vision, paid time off, retirement plans, and tuition reimbursement.
• Competitive pay based on education level and experience.

Working Conditions

• Bending - Rarely
• Climbing - Rarely
• Concentrating - Frequently
• Continuous Learning - Frequently
• Hearing: Conversation - Consistently
• Hearing: Other Sounds - Occasionally
• Interpersonal Communication - Frequently
• Kneeling - Rarely
• Lifting <10 Lbs. - Rarely
• Lifting 50+ Lbs. - Rarely
• Lifting <50 Lbs. - Rarely
• Pulling - Rarely
• Pushing - Rarely
• Reaching - Rarely
• Reading - Frequently
• Sitting - Frequently
• Standing - Rarely
• Stooping - Rarely
• Talking - Consistently
• Thinking/Reasoning - Frequently
• Use of Hands - Consistently
• Color Vision - Frequently
• Visual Acuity: Far - Consistently
• Visual Acuity: Near - Consistently
• Walking - Rarely

TriHealth Standards and Behaviors

• Serve: ALWAYS… Welcome everyone by making eye contact, greeting with a smile, and saying "hello".
• Excel: ALWAYS… Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met.
• Respect: ALWAYS… Respect cultural and spiritual differences and honor individual preferences.
• Value: ALWAYS… Value the time of others by striving to be on time, prepared and actively participating.
• Engage: ALWAYS… Acknowledge wins and frequently thank team members and others for contributions.