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Facility Clinical Documentation Specialist

Join TriHealth as a Facility Clinical Documentation Specialist!!! TriHealth is a place where skilled professionals can make a real impact, and the Facility Clinical Documentation Specialist plays a vital role in strengthening the accuracy, integrity, and financial health of our hospitals. In this position, you’ll partner closely with clinical teams, revenue integrity, and leadership to ensure complete and compliant charge capture, maintain a precise CDM, support EPIC conversions, and lead documentation‑driven process improvements. Your expertise will help shape pricing strategies, enhance documentation quality, and drive meaningful education across departments - directly influencing the clarity and accuracy of the care we deliver. At TriHealth, you’ll find a collaborative culture that values your voice, supports your growth, and empowers you to lead with confidence. You’ll work in an environment that encourages innovation, rewards initiative, and provides the resources needed to excel in complex revenue cycle and clinical documentation functions. If you’re motivated by problem‑solving, partnership, and elevating organizational excellence, TriHealth is a place where your skills will be recognized and your contributions will truly matter. Apply today and grow your career with a team that truly values you. Location:<ul style="list-style-type: disc;"><li>Work from Home</li></ul> Work Schedule:<ul style="list-style-type: disc;"><li>Full-Time (80 hours bi-weekly)</li><li>Day Shift</li><li>No Weekend, Holiday or On Call Commitment</li></ul> Benefits: TriHealth offers a comprehensive benefits package - including medical, dental, vision, paid time off, retirement plans, and tuition reimbursement. Please view our benefits page <a target="_blank" rel="noopener noreferrer" href="https://careers.trihealth.com/what-we-offer/benefits">https://careers.trihealth.com/what-we-offer/benefits</a> Job Requirements:<ul style="list-style-type: disc;"><li>Bachelor's Degree (Required)</li><li>Equivalent experience accepted in lieu of degree</li><li>5 - 7 years of healthcare knowledge typically obtained from experience as a clinical caregiver or manager, coding specialist, and/or a revenue integrity team member. (Required)</li><li>General understanding of hospital-based outpatient charging, coding, and/or revenue capture functions. </li><li>Knowledge of APC and OPPS reimbursement structures (preferred). </li><li>Strong project management skills. </li><li>Strong interpersonal skills, with demonstrated success at communicating effectively with all levels of the organization, especially senior leadership and department heads. </li><li>Skilled ability and comfort with electronic medical records (EPIC preferred), and hospital billing functions. </li><li>Proficient with personal computer applications (Excel, Word, and Power Point). </li><li>Effective organizational skills with the ability to prioritize and manage multiple functions and responsibilities simultaneously. </li><li>Ability to organize and work with minimum supervision at a high level of motivation and initiative while being entrepreneurial, creative and results oriented and must possess proactive orientation with a willingness to take managed risks. </li><li>Strong problem solving and investigative skills.</li><li>Registered Nurse Required or Licensed Practical Nurse Required or Other clinical certification/license Required or RHIA - Registered Health Information Administrator Required or RHIT - Registered Health Information Technician Required or Other ACDIS - Association of Clinical Documentation Integrity Specialists credential Required or CPC - Certified Professional Coder Required or Other COC - Certified Outpatient Coder Required or Other CDEO - Certified Documentation Expert Outpatient Required</li></ul> Job Overview: The Facility Clinical Documentation Specialist (CDS) is responsible for activities which assist the organization with processes for complete and accurate capture of charges and documentation in a compliant manner for the services rendered. This position will review assigned hospital services annually to support formulation of pricing strategies and monitor pricing and charge capture for TriHealth hospitals in conjunction with the Revenue Integrity and Internal Charge Audit departments. CDMs (charge description master) will be maintained with current and accurate revenue codes, CPT/HCPCS codes along with standardized descriptions and billing categories. This position will provide revenue cycle functions for CDM conversions to EPIC for any new acquired hospital-based entities. The CDS will also perform pre-billing financial audits of medical record documentation by comparing the documentation to detailed hospital account transactions. Detailed findings of charge error trends will be reported to clinical department management. The CDS assists clinical areas to understand the relationship of documentation, medical necessity, coding and charging for all services provided to the highest specificity. The CDS acts as a liaison for hospital charge capture to clinical teams, charge entry team members, IT, billing, and purchasing. The CDS provides education and training of staff related to these areas of oversight as well as coordinates with clinicians and providers for ongoing education. The CDS will also coordinate process mapping including information systems flowcharts, revenue capture responsibilities, and charge analyst functions. Job Responsibilities:<ul style="list-style-type: disc;"><li>Regularly conducts chart reviews of clinical departments to review documentation and charge accuracy to integrate into educational sessions with the clinical departments and medical staff. </li><li>Performs shadowing and coaching with key stakeholders in the clinical departments to facilitate adoption of best practices, document flow and improve documentation and charging accuracy. </li><li>Performs revenue optimization functions including: a. Review of accounts for potential missing documentation, coding and charging b. Identify root cause of missing charges c. Educate Clinical and Ancillary Departments d. Perform process improvement activities aimed at revenue optimization e. Coordinate with the Clinical Departments, Coding, CDM, and other key stakeholders to address and resolve root cause issues </li><li>Analyzes patient clinical and billing data and conducts chart reviews to identify documentation, coding, and charging opportunities. </li><li>Summarizes findings, prepares reporting and feedback for clinical departments and finance teams, and supports greater understanding and ownership of documentation and charge accuracy based on claim accuracy results. </li><li>Coordinates projects to build upon documentation improvement and charge capture processes for identified areas of opportunity. </li><li>Develops and maintains project plans and project tracking, including documentation of project meetings and project issues lists. </li><li>Maintains current knowledge of applicable regulatory standards, which may impact utilization of processes and systems</li></ul> Other Job-Related Information: Working Conditions: Bending - Rarely Climbing - Rarely Concentrating – FrequentlyHearing: Conversation – Consistently Hearing: Other Sounds - Occasionally Interpersonal Communication - FrequentlyKneeling - Rarely Lifting <10 Lbs. OccasionallyLifting 50+ Lbs. - Rarely Lifting <50 Lbs. - Rarely Pulling - Rarely Pushing - Rarely Reaching - Rarely Sitting - Consistently Standing - Occasionally Stooping – RarelyTalking - Consistently Use of Hands - Consistently Color Vision - Frequently Visual Acuity: Far - Occasionally Visual Acuity: Near - Consistently Walking - Occasionally TriHealth SERVE Standards and ALWAYS Behaviors At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following: Serve: ALWAYS… • Welcome everyone by making eye contact, greeting with a smile, and saying "hello" • Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist • Refrain from using cell phones for personal reasons in public spaces or patient care areas Excel: ALWAYS… • Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met • Offer patients and guests priority when waiting (lines, elevators) • Work on improving quality, safety, and service Respect: ALWAYS… • Respect cultural and spiritual differences and honor individual preferences. • Respect everyone’s opinion and contribution, regardless of title/role. • Speak positively about my team members and other departments in front of patients and guests. Value: ALWAYS… • Value the time of others by striving to be on time, prepared and actively participating. • Pick up trash, ensuring the physical environment is clean and safe. • Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste. Engage: ALWAYS… • Acknowledge wins and frequently thank team members and others for contributions. • Show courtesy and compassion with customers, team members and the community

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