Physician Clinical Documentation Specialist
TriHealthJoin TriHealth as a Physician Clinical Documentation Specialist!
At TriHealth, our Physician Clinical Documentation Specialists play a vital role in ensuring that clinical documentation accurately reflects patient complexity, risk, and the care our providers deliver. In this role, you’ll partner closely with physicians to strengthen documentation through pre‑visit HCC reviews or post‑claim E/M assessments, helping support accurate coding, compliant billing, and meaningful provider education. Your expertise directly contributes to TriHealth’s commitment to high‑quality, data‑driven, patient‑centered care.
We’re looking for candidates with strong clinical knowledge, critical thinking skills, and experience in coding or clinical practices supported by credentials such as CCS, CPC, CRCR, or nursing licensure. At TriHealth, you’ll join a collaborative, mission‑driven team where your analytical skills, communication strengths, and documentation insight make a measurable impact on both provider performance and patient outcomes.
Apply today and grow your career with a team that truly values you.
Location:
Works at Home
Work Schedule:
Full-Time (80 hours biweekly)
Day Shift
No Weekend, Holiday or On Call Commitment
Benefits:
TriHealth offers a comprehensive benefits package which includes 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:
Associate’s degree OR RN/LPN licensure OR coding certification with five years experience in ambulatory coding. (Required)
3 - 4 years of experience in a related field (Preferred)
Extensive clinical knowledge and understanding of anatomy and pathophysiology
Strong critical thinking skills and utilization of clinical knowledge to identify potential clinical indicators supporting patient complexity and clarifications of the medical record
Strong problem solving and investigative skills
Excellent written and verbal communication skills, including effective presentation skills
Demonstrates skilled ability and comfort with electronic medical records (EPIC preferred)
Proficient with personal computer applications (Excel, Word, and Power Point)
CCS - Certified Coding Specialist Required or CPC - Certified Professional Coder Required or
Certified Revenue Cycle Rep (CRCR) Required or Other Coding Credential Required and Registered Nurse Preferred or Licensed Practical Nurse Preferred
Job Overview:
The Physician Clinical Documentation Specialist (CDS) will serve as an advisor and expert resource for providers to improve the accuracy of clinical documentation to support patient complexity, risk profiles, and appropriate E/M levels, thereby supporting the provider's efforts and their professional fee billing. The Professional Fee CDS primarily assists providers in identifying clinically relevant information and capturing the clinical documentation needed to accurately reflect patient complexity. This Physician CDS may support one of two distinct workflows based on role assignment below: 1. Pre-Visit Workflow: Focuses on the capture and identification of chronic conditions reflected in Hierarchical Condition Categories (HCCs) during pre-visit chart reviews. These efforts assist in establishing accurate risk profiles and related health care costs. 2. Post-Claim Workflow: Focuses on post-claim, retrospective reviews of Evaluation and Management (E/M) encounters to highlight documentation opportunities based on provider medical decision making. The Physician CDS will coordinate with colleagues from the CDI Program and other members of the organization regarding provider education and training geared towards clinical documentation based on findings from pre-visit and post-visit documentation. The CDS will complete either pre-visit reviews or post-claim reviews, based on assigned role and daily workflow responsibilities, and will provide clear communication and education to providers on documentation, coding, and billing practices in adherence with compliance standards set by governing entities such as CMS, AHA, ACDIS, etc.
Job Responsibilities:
Conducts pre visit chart reviews to identify documentation gaps, chronic conditions, and suspect conditions, and prepare concise summaries with supporting evidence for providers.
Performs post claim E/M reviews to evaluate medical decision making, patient complexity, and documentation accuracy, identifying opportunities for improved code assignment and HCC capture.
Analyzes clinical documentation - including problem lists, historical notes, labs, medications, and specialist reports - to identify missing clinical indicators or descriptors needed to support diagnoses and billed levels of service.
Communicates effectively with providers, offering clarification when needed and providing compliant suggested documentation language to improve accuracy and completeness.
Delivers targeted provider education, including specialty specific tips, ongoing feedback, and sessions based on trends, chart review findings, and data analytics.
Collaborates with Professional Fee CDI leadership and cross functional teams, using performance and outcome data to identify high priority providers and supporting accurate reporting to coding/risk teams.
Maintains professional knowledge and standards, ensuring adherence to CMS and industry guidelines, staying current with HCC and E/M requirements, and upholding HIPAA confidentiality.
Working Conditions:
Bending - Rarely
Climbing - Rarely
Concentrating - Frequently
Continuous Learning - Frequently
Hearing: Conversation - Consistently
Hearing: Other Sounds - Occasionally
Interpersonal Communication - Frequently
Kneeling - Rarely
Lifting <10 Lbs. - Occasionally
Lifting 50+ Lbs. - Rarely
Lifting <50 Lbs. - Rarely
Pulling - Rarely
Pushing - Rarely
Reaching - Rarely
Reading - Consistently
Sitting - Consistently
Standing - Occasionally
Stooping - Rarely
Talking - Consistently
Thinking/Reasoning - 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