Facility Clinical Documentation Specialist

About This Role

Being a Facility Clinical Documentation Specialist at TriHealth means having a meaningful impact on clinical quality, documentation integrity, and revenue accuracy across outpatient services. You will collaborate closely with clinicians, leaders, and operational teams to strengthen documentation practices, optimize charge capture, and support compliant, high-quality patient care. Your expertise will directly influence organizational performance while allowing you to lead education, process improvement, and system-wide initiatives.

Responsibilities

• Regularly conduct chart reviews of clinical departments to review documentation and charge accuracy to integrate into educational sessions with the clinical departments and medical staff
• Perform shadowing and coaching with key stakeholders in the clinical departments to facilitate adoption of best practices, document flow, and improve documentation and charging accuracy
• Perform revenue optimization functions including:
• Review of accounts for potential missing documentation, coding, and charging
• Identify root cause of missing charges
• Educate Clinical and Ancillary Departments
• Perform process improvement activities aimed at revenue optimization
• Coordinate with the Clinical Departments, Coding, CDM, and other key stakeholders to address and resolve root cause issues
• Analyze patient clinical and billing data and conduct chart reviews to identify documentation, coding, and charging opportunities
• Summarize findings, prepare reporting and feedback for clinical departments and finance teams, and support greater understanding and ownership of documentation and charge accuracy based on claim accuracy results
• Coordinate projects to build upon documentation improvement and charge capture processes for identified areas of opportunity
• Develop and maintain project plans and project tracking, including documentation of project meetings and project issues lists
• Maintain current knowledge of applicable regulatory standards, which may impact utilization of processes and systems

Requirements

• Bachelor’s Degree
• Registered Nurse or Licensed Practical Nurse, or Registered Health Information Administrator, or Registered Health Information Technician, ACDIS - Association of Clinical Documentation Integrity Specialists credential, or Certified Professional Coder, Certified Outpatient Coder, or Certified Documentation Expert Outpatient
• General understanding of hospital-based outpatient charging, coding, and/or revenue capture functions
• Strong project management skills
• Strong interpersonal skills, with demonstrated success at communicating effectively with all levels of the organization, especially senior leadership and department heads