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Clinical Documentation Specialist
OhioHealth. Review inpatient medical records to identify documentation opportunities reflecting severity of illness and risk of mortality .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expert knowledge of clinical documentation requirements, coding guidelines, and DRG assignment while effectively collaborating with healthcare providers and HIM coding staff to ensure compliance and accuracy in documentation. Possesses strong critical reasoning and communication skills to facilitate education and query resolution.
Highest-signal resume keywords
Bachelor's Degree In NursingCurrent RN License In OhioExpert Knowledge Of Clinical Documentation RequirementsCompetency In ICD-10 Documentation RequirementsMinimum 5 Years Experience In Inpatient Medical/Surgical Or Critical Care
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Documentation RequirementsCoding GuidelinesDRG AssignmentICD-10 RequirementsCritical Reasoning SkillsData InterpretationDocumentation AuditsQuery ResolutionClinical Decision MakingProblem Solving
Soft Skills
Interpersonal SkillsCommunication SkillsOrganization SkillsFlexibilityPositive Attitude
Tools & Technologies
Microsoft WordMicrosoft ExcelEHR Applications
Certifications & Qualifications
Registered Nurse License
Industry Keywords
AHIMA Standards Of Ethical CodingCompliance StandardsHospital Quality MetricsHealthcare Regulations
About the role
Key responsibilities & impact- Review inpatient medical records to identify documentation opportunities reflecting severity of illness and risk of mortality
- Identify principal and secondary diagnoses, comorbidities, complications, CCs, and MCCs using clinical criteria
- Concurrently assign DRGs and capture documentation specificity supporting diagnoses and clinical indicators
- Attend multidisciplinary rounds and communicate with providers
- Submit verbal, electronic, or written queries requesting clarification or additional documentation
- Escalate unanswered queries and communicate with physician advisors
- Collaborate with HIM coding staff to ensure accurate clinical documentation and resolve coding discrepancies
- Apply clinical documentation requirements, coding guidelines, DRG assignment standards, compliance standards, and ICD-10 requirements
- Participate in documentation or query audits and support interdepartmental compliance
- Assist with provider and departmental education, including courses, printed materials, and presentations
Requirements
What you’ll need- Bachelor's Degree in Nursing
- Current RN (Registered Nurse) license in the State of Ohio from the Ohio Board of Nursing
- Minimum 5 years of experience in an adult inpatient medical/surgical or critical care setting
- Critical reasoning skills in clinical decision making and problem solving
- Ability to interpret data
- Flexible, positive, and clear interpersonal and communication skills
- Ability to provide information collaboratively with physicians and other staff
- Organization and computer skills
- Expert knowledge of clinical documentation requirements, coding guidelines, DRG assignment, and clinical conditions and procedures
- Understanding of compliance standards, AHIMA Standards of Ethical Coding guidelines, hospital quality metrics, and healthcare regulations
- Competency in ICD-10 documentation requirements
- Working knowledge of Microsoft Word, Excel, and facility-based EHR applications
Benefits
Comp & perks- Full-time schedule with 40 scheduled weekly hours
- Day shift