Clinical Documentation Specialist

Trinity Health

. Direct efforts toward the integrity of clinical documentation as reviewer, educator, and consultant .

Posted 10/28/2026full-timeRemote • Ohio • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in clinical documentation integrity, coding standards, and effective communication with healthcare professionals. Proficient in conducting medical record reviews and educating clinical staff on documentation requirements.

Highest-signal resume keywords

Clinical Documentation IntegrityCoding ExpertiseEffective CommunicationMedical Record ReviewHealthcare Collaboration

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Clinical Documentation RequirementsCoding DefinitionsQuery StandardsMedical NecessitySeverity of Illness AssessmentRisk of Mortality AssessmentInpatient CodingPerformance Improvement ActivitiesDocumentation ReviewEducational Session Facilitation

Soft Skills

Effective Written CommunicationEffective Verbal Communication

Tools & Technologies

Computer SystemsDocumentation Software

Certifications & Qualifications

RHIARHITCCDSCDIPCCS

Industry Keywords

Clinical Documentation SpecialistInpatient CareCritical Care NursingSurgical Inpatient CareHealthcare Team Collaboration

About the role

Key responsibilities & impact

Direct efforts toward the integrity of clinical documentation as reviewer, educator, and consultant
Conduct concurrent reviews of selected patient records for legibility, clarity, completeness, consistency, and precision
Ensure documentation accurately reflects severity of illness, risk of mortality, medical necessity, 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
Use computer systems effectively and maintain records of reviews, queries, and physician responses
Participate in performance improvement activities, in-service programs, staff meetings, and committees
Report actual or potential wrongdoing and perform other assigned duties

Requirements

What you’ll need

Associate/Diploma Degree in Nursing or Health Information Technology (HIT), or an advanced degree in nursing (NP/APN) or Physician Assistant
In the absence of a college degree, 3 or more years of experience as an inpatient coder or clinical documentation specialist
RHIA, RHIT, CCDS, CDIP, or CCS certification considered in lieu of an RN
Experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, PA, NP/APN, or as an inpatient coder preferred
Clinical and coding expertise
Ability to conduct extensive medical record review
Knowledge of clinical documentation requirements, coding definitions, query standards, and policies
Effective written and verbal communication with physicians and healthcare team members
Proficiency with computer systems and maintaining review/query records

Benefits

Comp & perks

Medical, dental, and vision 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
DailyPay access for eligible colleagues
Diversity, Equity, and Inclusion Colleague Resource Groups