Ohio Licensed Clinical Documentation Specialist

Job Summary

To support accurate medical record documentation, the full-time Ohio Licensed Clinical Documentation Specialist will review inpatient records, collaborate with providers, and ensure compliance with clinical documentation standards while working remotely from Ohio.

Key responsibilities

• Reviews inpatient medical records to identify documentation opportunities that accurately reflect severity of illness and risk of mortality
• Communicates with providers to request clarification or additional documentation, managing queries and escalations as necessary
• Collaborates with coding staff to ensure accurate documentation and participates in education initiatives for providers and departments

Required qualifications

• Bachelor's Degree in Nursing with a current RN license in Ohio
• Minimum of 5 years of experience in an adult inpatient medical/surgical or critical care setting
• Expert knowledge of clinical documentation requirements, coding guidelines, and DRG assignment
• Strong critical reasoning skills in clinical decision-making and data interpretation
• Proficiency in computer-based applications, including Word, Excel, and Electronic Health Records (EHR)