Physician Clinical Documentation Specialist

Job Description Join 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