Clinical Documentation Specialist II

Join Our Team as a Clinical Documentation Specialist II!

Join TriHealth as a Clinical Documentation Specialist II and partner with interdisciplinary teams to improve documentation accuracy, support quality outcomes, and elevate patient care. Apply today and be part of a team that is passionate about making a difference.

We offer career growth opportunities, and a comprehensive benefits package.

Location: 

• Remote

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

Work Schedule: 

• Full time

• Day shift

• No weekend or holiday rotation required

Incentives & Benefits: 

We offer a comprehensive benefits package, including medical, dental, vision, paid time off, retirement plans, and tuition reimbursement. 

https://careers.trihealth.com/what-we-offer/benefits

Job Requirements:

• Bachelor's Degree in Nursing; Business, Education, HIM, 

• CCDS - Certified Clinical Documentation Specialist

• Registered Nurse 

• Advanced CDI certification if available

• Computer aptitude including but not limited to electronic medical record clinical documentation software programs, Word, Excel and PowerPoint

• 5-7 years experience Clinical Nursing 

• 2-3 years experience Clinical Documentation

Job Overview:

• The Clinical Documentation Specialist II reports to the Clinical Documentation Department Manager. This team member assists with the delivery of clinical documentation strategies within the workplace that positively impact and drive change to attain organizational goals as well as maintain documentation standards as set by government and corporate guidelines, The Clinical Documentation Specialist II requires an advanced level of knowledge and experience for the successful management of clinical education in their specialty area, quality monitoring, documentation review and the ability to communicate this knowledge to team members throughout the organization, including Medical Staff Departments. They will serve as a subject matter experts in their specialty field which includes but is not limited to preparing and presenting a minimum of two educational topics each calendar year for the benefit of the medical staff, APNs, residents and/or team members as well as being responsible for specialty specific orientation to new team members or those who need refreshers. They will participate in peer interviews and leadership opportunities such as serving on committees, leading journal club or conducting a review course for team members interested in certification. This position requires a professional who works well independently but also values team and possesses excellent communication skills.
   

Job Responsibilities:

• Documentation Improvement - record review rate of at least 98%. Severity clarification rate of at least 25%. DRG shift clarification rate of at least 15%. 
  Provides Informal education includes sharing with team members in assigned patient care area, inpatient coding department and clinical documentation team advanced or new strategies for capturing highest level of SOI/ROM, denial prevention, and determining PSIs. Documentation of informal education with physicians, APNs, residents on documentation strategies and their importance. 

• Maintains specialty certification and pursue advanced CDI certification within 1 year of certification becoming available. A minimum of two formal presentations per year on pertinent advanced CDI topics at monthly team meetings, resident or medical staff meetings.

• Participates in department or hospital committees such as Stroke Committee, Task Force, etc., new team member specialty orientation leader or participating as part of the peer interview team. Other options include but are not limited to leading a department journal club or participating in a minimum of 10 hours of approved community service per year.

Other Job-Related Information:

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