Clinical Documentation Specialist

Trinity Health

. Conduct concurrent reviews of selected patient records for legibility, clarity, completeness, consistency, and precision of clinical documentation.

Posted 11/10/2026part-timeRemote • Ohio • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical documentation review, ensuring accuracy and compliance with healthcare standards. Proficient in collaborating with healthcare professionals and conducting educational sessions to enhance documentation practices.

Highest-signal resume keywords

Clinical Documentation ReviewInpatient CodingCritical Care ExperienceCommunication SkillsCollaboration with Healthcare Teams

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical DocumentationCoding DefinitionsPatient Record ReviewDocumentation AccuracyPerformance Improvement Activities

Soft Skills

Educational FacilitationInterpersonal CommunicationProfessional Growth Promotion

Tools & Technologies

Computer Systems for Record Maintenance

Certifications & Qualifications

RHIARHITCCDSCDIPCCS

Industry Keywords

Health Information TechnologyNursingInpatient CarePatient Care ServicesOrganizational Integrity

About the role

Key responsibilities & impact

Conduct concurrent reviews of selected patient records for legibility, clarity, completeness, consistency, and precision of clinical documentation.
Ensure documentation accurately reflects severity of illness, risk of mortality, and services provided.
Serve as a resource on appropriate clinical documentation.
Communicate documentation discrepancies and coding definitions to physicians in writing and verbally.
Conduct one-to-one educational sessions with physicians and healthcare team members.
Collaborate with physicians, patient care services, case management, coding specialists, and other healthcare disciplines.
Maintain records of completed reviews, queries, and physician responses using computer systems.
Participate in performance improvement activities, in-service programs, staff meetings, and committees as requested.
Promote workplace safety, relationship-based care, professional growth, and organizational integrity.
Perform other duties as assigned.

Requirements

What you’ll need

Must possess an Associate/Diploma Degree in Nursing, Health Information Technology (HIT), an advanced degree in nursing (NP/APN), or be a Physician Assistant.
In the absence of a college degree, must have 3 or more years’ experience as an inpatient coder or clinical documentation specialist.
RHIA, RHIT, CCDS, CDIP, or CCS will be considered in lieu of a RN.
Experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), or as an inpatient coder preferred.
Must work 4 hours a day, 5 days a week, Monday–Friday.
Meets population-specific and department competencies.
Utilizes computer systems effectively and maintains records of reviews, queries, and physician responses.

Benefits

Comp & perks

Competitive compensation and benefits packages including medical, dental, and vision with coverage starting on day one.
Retirement savings account with employer match starting on day one.
Generous paid time off programs.
Employee recognition programs.
Tuition/professional development reimbursement.
Relocation assistance (geographic and position restrictions apply).
Discounted tuition and enrollment opportunities at the Mount Carmel College of Nursing.
Employee Referral Rewards program.
Mount Carmel offers DailyPay - if you’re hired as an eligible colleague, you’ll be able to see how much you’ve made every day and transfer your money any time before payday.
Opportunity to join Diversity, Equity, and Inclusion Colleague Resource Groups.