Share this Job


City:  Montgomery
State:  OH
Job Requisition Number:  251683


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.



EDUCATION: Bachelor's Degree in Nursing or other Healthcare Field, BLS/CPR (Basic Life Support for Healthcare Providers)

EXPERIENCE: 5-7 years experience in adult acute inpatient hospital setting - nursing, pharmacy, respiratory

DEPARTMENT SPECIFIC QUALIFICATIONS: In order to be successful the clinical documentation specialist must possess the ability to communicate effectively verbally and in written form with medical records staff, residents, physicians and all members of the health care team.  They must be organized, critical thinkers, work well independently and possess excellent keyboard skills.  Knowledge of CMS guidelines, coding clinics and previous clinical documentation is a plus


Team members work remotely 1 day a week, hybrid position.  Flexible start time between 6:30AM-9:00AM.  

Nearest Major Market: Cincinnati

Job Segment: Clinic, Medical, Pharmacy, Respiratory, Medical Research, Healthcare