Facility Outpatient Clinical Documentation Specialist

Remote Full-time
Join TriHealth as a Facility Outpatient Clinical Documentation Specialist!!!

At TriHealth, you’ll be part of a mission‑driven health system that empowers you to make a meaningful impact on clinical quality, documentation integrity, and revenue accuracy across outpatient services. In this role, you’ll 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.

TriHealth is consistently recognized as one of the region’s top employers, offering a supportive culture, strong leadership engagement, and opportunities for professional growth. You’ll work within a collaborative environment that values innovation, continuous learning, and the contributions of experienced professionals. With robust benefits, a commitment to work‑life balance, and a focus on employee well‑being, TriHealth provides a workplace where you can thrive and advance your career.

Apply today and grow your career with a team that truly values you.

Location:
• Work from Home

Work Schedule:
• Full-Time (80 hours bi-weekly)
• Day Shift
• No Weekend, Holiday or On Call Commitment

Benefits:

TriHealth offers a comprehensive benefits package - including medical, dental, vision, paid time off, retirement plans, and tuition reimbursement. Please view our benefits page https://careers.trihealth.com/what-we-offer/benefits

Job 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
• Knowledge of APC and OPPS reimbursement structures (preferred).
• 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.
• Skilled ability and comfort with electronic medical records (EPIC preferred), and hospital billing functions.
• Proficient with personal computer applications (Excel, Word, and Power Point).
• Effective organizational skills with the ability to prioritize and manage multiple functions and responsibilities simultaneously.
• 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.
• Strong problem solving and investigative skills.
• 5-7 years’ experience of healthcare knowledge typically obtained from experience as a clinical caregiver or manager, coding specialist, and/or a revenue integrity team member.

Job Overview:

The Facility Outpatient Clinical Documentation Specialist (CDS) is responsible for activities which assist the organization with processes for complete and accurate capture of documentation and charges in a compliant manner for the outpatient services rendered. The Outpatient CDS assists clinical areas to understand relationship of documentation, medical necessity, coding and charging for all services provided to the highest specificity. The Outpatient 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 analysts’ functions.

Job 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.
• 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.
• Performs 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
• Analyzes patient clinical and billing data and conducts chart reviews to identify documentation, coding, and charging opportunities.
• 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.
• Coordinates projects to build upon documentation improvement and charge capture processes for identified areas of opportunity.
• Develops and maintains project plans and project tracking, including documentation of project meetings and project issues lists.
• Maintains current knowledge of applicable regulatory standards, which may impact utilization of processes and systems.

Other Job-Related Information:

Working Conditions:

Bending - Rarely
Climbing - Rarely
Concentrating – Frequently

Hearing: Conversation – Consistently
Hearing: Other Sounds - Occasionally
Interpersonal Communication - Frequently

Kneeling - Rarely
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