Ohio Licensed Clinical Documentation Specialist

Job Summary

Utilizing independent clinical judgment, the full-time Ohio Licensed Clinical Documentation Specialist will ensure the accuracy and completeness of provider-based clinical documentation in medical records while collaborating with healthcare providers in a remote work environment.

Key responsibilities

• Perform timely medical record reviews to ensure accurate documentation and coding, following up with clinical providers for necessary clarifications
• Educate and engage healthcare team members on effective documentation practices through various formats, including clinical rounding and focused education sessions
• Identify and escalate query opportunities to enhance documentation integrity and ensure compliance with regulatory guidelines

Required qualifications

• Associate's Degree in a health-related field or a diploma in Nursing (Required); Bachelor's Degree preferred
• 3+ years of clinical and/or ICD-10 coding experience, preferably in a large academic medical center (Required)
• 1+ years of experience using clinical computer systems (Required)
• Current Ohio RN license or Registered Health Information Administration (RHIA) or Registered Health Information Technologist (RHIT) certification (Required upon hire)
• Thorough knowledge of clinical skills, disease pathophysiology, and relevant coding guidelines (Required proficiency)