Clinical Documentation Specialist at OhioHealth reviewing inpatient medical records for severity of illness and risk of mortality. Collaborating with providers to enhance clinical documentation accuracy in a supportive environment.
Responsibilities
Reviews inpatient medical records and identifies potential opportunities in provider documentation to accurately reflect severity of illness (SOI) and risk of mortality (ROM)
Communicates with provider or designee to request clarification or additional documentation
Exhibits expert knowledge of clinical documentation requirements, coding guidelines, DRG assignment, and clinical conditions
Collaborates with the Health Information Management Department coding staff regarding clinical documentation
Assists with implementing plans for both formal and informal education of providers and other departments
Requirements
Bachelor's Degree (Required)
RN - Registered Nurse - Ohio Board of Nursing
Minimum 5 years Experience in adult inpatient medical/surgical or critical care setting
Certification in health-related field or Clinical Documentation Improvement
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