Registered Nurse – Clinical Documentation Specialist

apartment TriHealth location_onCincinnati, OH, US

Job Description

Join TriHealth as a Clinical Documentation Specialist and partner with interdisciplinary teams to improve documentation accuracy, support quality outcomes, and elevate patient care.

Work Hours

Full time w/benefits
64 hours biweekly, day shift
No weekend and holiday rotation

Selection Process

As part of the selection process, candidates will be required to complete a pre‑employment assessment test. Candidates who successfully pass the assessment may be considered for the next steps in the selection process, including interviews.

Job Requirements

Bachelor's degree in nursing. Equivalent experience accepted in lieu of degree
Active valid Registered Nurse (RN) license in the state of Ohio. Basic Life Support for Healthcare Providers (BLS)
5-7 years' experience Clinical in Nursing
Basic knowledge of keyboarding and Microsoft office

Job Overview

Concurrently review inpatient medical records for accuracy and completeness of documentation on admission and throughout hospitalization.
Ensure the accuracy and completeness of clinical information within the chart by analyzing for potential gaps in physician documentation through clarifications to improve documentation on principal diagnosis, co-morbidities, present on admission and quality core measures.
Facilitate improvement in clinical documentation through education and extensive interaction with physicians, nursing staff and all other members of the health care team. Systematic development and implementation of educational opportunities for physicians, nursing staff and all other members of the health care team.
Collaboration with coding staff in assuring complete and compliant documentation in all inpatient charts at time of discharge. Participates in the interdisciplinary process to ensure that selected clinical quality indicators are met.

Job Responsibilities

Facilitates the accurate representation of the severity of illness on TriHealth hospital records by performing admission/continued stay reviews using Clinical Documentation guidelines and standard performance measures.
Processes discharges by updating the Documentation Worksheet to reflect any changes in status, procedures/treatments, and conferring with the physician to finalize diagnoses.
Accurately documents data into CDMP Trak.
Reviews clinical issues with coding staff to assign a working DRG and to resolve discrepancies.
Educates all internal customers on compliant documentation opportunities, coding and reimbursement issues. This standard includes formal presentations at physician meetings nursing and other staff meetings.
Improves documented compliance of selected clinical quality indicators and problems present on admission.

Working Conditions

Climbing - Rarely

Hearing: Conversation - Consistently

Hearing: Other Sounds - Consistently

Kneeling - Occasionally

Lifting 50+ Lbs. - Rarely

Lifting <50 Lbs. - Occasionally

Pulling - Frequently

Pushing - Consistently

Reaching - Frequently

Sitting - Rarely

Standing - Consistently

Stooping - Occasionally

Talking - Consistently

Use of Hands - Consistently

Color Vision - Frequently

Visual Acuity: Far - Consistently

Visual Acuity: Near - Consistently

Walking - Consistently

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

About The Team

Nurses are at the heart of patient care, and we are proud to have such amazing nurses here at TriHealth. As the region’s leading health system, we are focused on consistency in the patient experience and standardizing nursing care across the system with proven best practices. We aim to continue leading research supporting the evolution of nursing care, especially as TriHealth works to adapt the population health model system-wide.

In order to lead these changes, TriHealth must invest in our nurses, which is why we provide multiple opportunities for nurses to achieve their professional development goals through tuition reimbursement programs, specialty certifications and several other continuing education opportunities. Our registered nurses support TriHealth in many different aspects of nursing, including patient care, care coordination, education and management.

If you’re interested in joining our world-class nursing team, you can see all current nursing opportunities here on TriHealth.com.

I am honored to lead our TriHealth nursing team, and welcome you to join us!

Share this job

Related Jobs

Per Diem

Registered Nurse (RN)

apartment IntelyCare location_onMonroe, OH

$38 - $68 / HOUR

Free yourself with truly flexible schedules and earn up to $68 as a Registered Nurse (RN) in the Cincinnati suburb of Monroe, Ohio, and surrounding areas. IntelyCare was founded by nurses, for nurses, so we understand just how valuable work-life balance is for nursing professionals. Our staff have the freedom to choose the shifts at our partner facilities that best fit their unique lives — and to take time off whenever they like. Maybe you need some flexibility so you can attend classes at Galen College while still earning an income. Perhaps you enjoy meeting friends at the Traders World Flea Market, followed by lunch, every Saturday. Don't like working night shifts? No problem. Whatever makes your life full, we've got your back. Take a look at our other perks and benefits and consider applying with us today. Benefits RN hourly rate between $38 and $68 Get paid rates that are up to 25% higher on average, with weekly and daily pay options Opportunities for overtime as well as boosted rates for holidays Quickly find shifts in all states where you're authorized to practice Set your own schedule by selecting only your preferred shifts at any of our partner facilities Choose from weekday/weekend shifts, day/evening/overnight shifts, and more 401k retirement plan Upskilling opportunities with a dedicated team of quality assurance nursing professionals Eligibility for medical, dental, and vision insurance for you and qualifying family members Employer tax withholding each pay period Employer coverage for workers' comp and malpractice insurance Undergraduate and graduate tuition discounts at Excelsior University (up to 34%) Manage your shifts and access workplace perks like free continuing education courses through an all-in-one app At IntelyCare, you get a job and a schedule that you manage, but also a supportive community that has your back. Here's how some of our own nursing professionals have described the experience: "I love working with IntelyCare because of all the perks and benefits it provides. There are a variety of facilities to choose from in the app. At first I was going to multiple facilities until I found my two favorites, where I now work full time. I love it!" "I love how flexible this job is! I am a busy mom, so accepting last minute ‘hero’ shifts typically works out better than scheduling shifts in advance. I appreciate the pay and the additional bonuses." "IntelyCare has exceptionally high rates, a variety of facilities, and an easy and fun app to use. The staff here are all very personable and knowledgeable as well, which makes things so much easier. This is truly a 5-star agency." "I love IntelyCare because everything has been easy from the application process until now. There has never been a question unanswered, and everyone is always happy to help with whatever I needed. They always advocate on our behalf. I am so grateful to be an IntelyPro." Job Responsibilities Providing high-quality RN care in post-acute facilities Reviewing various care options with the medical team, residents, and their family members Coordinating with clinical teams to develop individualized care plans Being accountable to follow and adhere to resident care plans Administering appropriate medications and treatments to residents Drawing fluids as needed for labs and testing Using and monitoring medical equipment and devices to ensure effectiveness Training and supervising nursing professionals and other care staff consistent with scope of practice guidelines Promoting staff compliance with all applicable laws, regulations, facility policies, and nursing standards of care Documenting all relevant data to include vital signs, nursing interventions and responses, and resident histories Assisting staff members with incident investigations and the development of care best practices Qualifications and Skills Current Ohio state license to practice as a Registered Nurse (RN) 6 months of experience (in an RN or related role) Completion of an approved nursing program High level of organizational skills Demonstrated ability to effectively communicate across medical and nursing teams Ability to lift at least 50 lbs Ready for a Job That Puts Your Needs First? As you search for Registered Nurse (RN) jobs in your area, you don't have to settle for the work-life imbalance that you may be used to. If you're ready for something better, we're ready for you. Take the next step today by applying to the team ranked #1 in quality. We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status. Location: Monroe, Ohio 45050

Other

Per Diem Registered Nurse - Blue Ash, OH - Gastro Health

apartment Gastro Health location_onHamilton, OH

To support our continued growth, we are seeking a Per Diem Registered Nurse to join our endoscopy team in Liberty Township , Ohio . Gastro Health is an extensive and diverse group of professionals dedicated to digestive and liver health. Now with 150 locations in seven states, our team of physicians, advanced practice providers, nutritionists, technicians, and support team are on a mission to provide outstanding medical care and an exceptional healthcare experience. What makes Gastro Health different? Collaboration: We strive to ensure a shared workload among you and your colleagues and a reasonable patient volume. Stability: We care about your mental well-being as much as your financial success. That’s why we offer competitive compensation without sacrificing all your free time. Support: This position offers a great work/life balance – no weekends or evening hours. We are growing rapidly and support internal advancement. Security: We offer a competitive compensation package. Job Duties Compliance with all clinical policies and procedures, systems and applications. Develops and maintains a clean, safe and pleasant environment. Proper assisting to the physicians before, during and after procedures. Performs nursing assessment of patient prior to, during and after the procedure. Administration of conscious sedation and topical anesthetics under MD supervision. Maintains competencies in all areas of endoscopy. Patient education. Proper documentation of all pertinent information regarding the care of patient; this should be done in an adequate and timely manner. Become trained and proficient in all essential work areas of the center. Inventory and inspection of all supplies and equipment both before and after performing cases. Knows how to operate and troubleshoot equipment in center. Maintains current knowledge of all GI procedures. Maintains log books in regards to physicians, biopsies, etc. Follows center protocol for reprocessing equipment. Serves as an active participant on committees, as assigned. Attends all staff meetings and in-service classes on regularly scheduled days. Performs other related duties as requested or required by the Director of Nursing or Governing Body. Overseeing and participating in procedure room prep and flow. Post-anesthesia care and discharging of patients. Train and mentor other staff. Physical Activities and Requirements Possesses good physical health, capable of working in a demanding environment. Able to perform the basic functions of the job including extended hours, standing, bending, and stretching with frequent trips to all areas of the Center. Able to lift, and carry supplies and equipment as needed. Possessed manual dexterity, hearing acuity, and visual acuity are important to the performance of the job tasks. Speaks clearly and distinctly to perform extensive communication with other staff member, patients and their families /escorts and physicians. Appears professional at all times. Wears scrub attire as dictated in the Center’s dress code. Candidate requirements Active RN license in the state of Ohio 1 year of RN experience is preferred, but new grads are welcome Recovery room experience a plus IV skills are a plus BLS and ACLS Gastro Health is proud to be an Equal Opportunity Employer. We do not discriminate based on race, color, gender, disability, protected veteran, military status, religion, age, creed, national origin, gender identity, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law. We thank you for your interest in joining our growing Gastro Health team!

Med-Surg

Full-time

Registered Nurse (RN), Liberty med/surg - 36 hours/week, PM Shift (Experienced RNs)

apartment Cincinnati Children's location_onLiberty Township, OH

JOB RESPONSIBILITIES Compliance - Patient Services Staff - Sustain a working understanding of regulatory requirements and accreditation standards. Support leadership in Compliance efforts to meet and sustain the regulatory compliance efforts of the department and hospital. Be mindful and judicious in monitoring safety and departmental policies and procedures. Ensure all individual certifications and Safety College requirements are fulfilled in a timely basis. Work with department managers, nurse council and magnet representatives to identify and share safety best practices. Be mindful of CCHMCs processes and compliance with CMS standards and freely communicate safety and compliance concerns to leadership team members. Uses systems thinking - Sees the pieces or components; sees patient and family within the isolated environment of the unit; sees self as key resource to support the family through the healthcare experience through care coordination. Sustains a working understanding of regulatory requirements and accreditation standards. Supports leadership in efforts to meet and sustain the regulatory compliance efforts of the department and hospital. Monitors and complies with safety and departmental policies and procedures. Ensures individual certifications and Safety College requirements are fulfilled in a timely basis. Is mindful of CCHMCs processes and compliance with CMS standards and freely communicates safety and compliance concerns to leadership team members. Clinical judgment when performing caring practices - Collects clinical data; follow algorithms, decision trees, and protocols. Matches formal knowledge with clinical events to make appropriate decisions; uses available resources as needed. Documents plan of care, care delivered, and patient and family outcomes. Focuses on the usual and customary needs of the patient and family; anticipates future needs; bases care on standards and protocols; maintains a safe physical environment; acknowledges death as a potential outcome. Consistently integrates age specific concepts into patient care, taking into consideration both the patient's chronological age and developmental functioning. Using self-management support, develops care goals and actions through partnerships with patients and families. Facilitates patient and family learning by providing structured education based on the plan of care goals, and the needs of the patient and family; uses teach back to evaluate effectiveness. Clinical inquiry & performance review to improve practice - Follows standards and guidelines; implements clinical changes and research-based practices developed by others; recognizes the need for further learning to improve patient care; recognizes routine or obvious changing patient situation (e.g., deterioration, crisis); in unusual care situations, seeks help when needed to identify patient problem. Uses self-appraisal performance review and peer review, including annual goal setting, for assurance of competence and professional development to promote safe and ethical practice using the nursing process. Demonstrates openness to coaching and mentoring from others. Facilitates learning by assisting with peer and student learning experiences. Works with department managers, nurse council and magnet representatives to identify, share, implement and evaluate safety best practices. Collaborates with team using shared decision making - Is receptive to the contributions of the interdisciplinary team in team meetings and discussion regarding patient issues. Participates in shared governance at the point-of-care as a member of unit-based councils or by demonstrating awareness and contributing to shared decision making (reading minutes, giving feedback and implementing council decisions). Interprofessional Practice - Demonstrates consistent integration of the Interprofessional Practice Model (IPM) in all aspects of practice. Exhibits advocacy, moral agency and response to inclusion - Works on behalf of patient and family; assesses personal values; aware of ethical conflicts/issues that may surface in clinical setting; makes ethical/moral decisions based on rules; represents patient when patient cannot represent self; aware of patients' rights. Assesses cultural inclusion. Recognizes the potential impact of culture on the patient/family experience, and incorporates culturally inclusive concepts into patient care. Patient Care - Age Specific and Culturally Inclusive - Consistently integrates age specific and culturally inclusive concepts into patient care, taking into consideration both the patient's chronological age and developmental functioning. JOB QUALIFICATIONS Associate/Diploma prepared RNs from ACEN, CCNE or NLN CNEA accredited institution requires 2+ years of experience. If hired without a BSN or MSN, must enroll in a BSN or MSN program within 1 year of hire date/RN job date and complete program within 5 years of hire/RN job date. Preferred: BSN from ACEN, CCNE or NLN CNEA accredited institution or MSN. Active Ohio RN License. May be required to obtain other state licensure. Foreign graduates must have license validated through TruMeritTM per Ohio Board of Nursing code for Foreign Graduates. Primary Location Liberty LA Schedule Full time Shift Night (United States of America) Department LA4-2 Employee Status Regular FTE 0.9 Weekly Hours 36 About Us At Cincinnati Children’s, we come to work with one goal: to make children’s health better. We believe in a holistic team approach, both in caring for patients and their families, and in advancing science and discovery. We strive to do better and find energy and inspiration in our shared purpose. If you want to be the best you can be, you can do it at Cincinnati Children’s. Cincinnati Children's is: Recognized by U.S. News & World Report as a top 10 best Children's Hospitals in the nation for more than 15 years Consistently among the top 3 Children's Hospitals for National Institutes of Health (NIH) Funding Recognized as one of America’s Best Large Employers (2025) , America’s Best Employers for New Grads (2025) One of the nation's America’s Most Innovative Companies as noted by Fortune Consistently certified as great place to work A Leading Disability Employer as noted by the National Organization on Disability Magnet® designated for the fourth consecutive time by the American Nurses Credentialing Center (ANCC) We Embrace Innovation—Together. We believe in empowering our teams with the tools that help us work smarter and care better. That’s why we support the responsible use of artificial intelligence. By encouraging innovation, we’re creating space for new ideas, better outcomes, and a stronger future—for all of us. Comprehensive job description provided upon request. Cincinnati Children’s is proud to be an Equal Opportunity Employer committed to creating an environment of dignity and respect for all our employees, patients, and families. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, genetic information, national origin, sexual orientation, gender identity, disability or protected veteran status. EEO/Veteran/Disability

Per Diem

Registered Nurse (RN)

apartment IntelyCare location_onMaineville, OH

$38 - $68 / HOUR

At IntelyCare, you can make up to $68 an hour as a Registered Nurse (RN) in Maineville, OH, and surrounding areas, with a truly flexible and self-managed schedule. This means you can choose the shifts at any of our partner facilities that best fit your life, take time off whenever you like, and enjoy the professional support and benefits that come with W2 employment. As a nurse-founded company, we understand that happy, fulfilled nursing professionals are the most reliable clinicians and provide excellent care. Who says you can't enjoy a real work-life balance and work in the demanding field of healthcare? Planning an outing with your mom at a Marmalade Lily U-Pick Flowers event? Need some more flexibility so you can walk your dog around Central Park and catch up with friends every Friday morning? Maybe you just need a day to relax at home with a good book. Whatever you needs, on our team you get to schedule work around them. Check out more of what we offer below and see how you can be a part of our supportive team by applying today. Benefits RN hourly rate: $38 to $68 Rates that are up to 25% higher on average Weekly and daily pay options Opportunities for overtime and boosted rates for holidays Ability to quickly search for shifts in all states where you're authorized to practice Your choice of a wide range of shifts at any of our partner facilities — including weekday/weekend shifts, day/evening/overnight shifts, and more Medical, dental, and vision insurance (includes qualifying family members) Employer tax withholding Eligibility for 401k retirement plan Opportunities to upskill with a dedicated staff of quality assurance nursing professionals Undergraduate and graduate tuition discounts (up to 34%) at Excelsior University Workers' comp coverage and malpractice insurance (employer paid) All-in-one app to easily manage your shifts and workplace perks like free continuing education courses At IntelyCare, you get a job and a schedule that you manage, but also a supportive community that has your back. Here's how some of our own nursing professionals have described the experience: "I love working with IntelyCare because of all the perks and benefits it provides. There are a variety of facilities to choose from in the app. At first I was going to multiple facilities until I found my two favorites, where I now work full time. I love it!" "I love how flexible this job is! I am a busy mom, so accepting last minute ‘hero’ shifts typically works out better than scheduling shifts in advance. I appreciate the pay and the additional bonuses." "IntelyCare has exceptionally high rates, a variety of facilities, and an easy and fun app to use. The staff here are all very personable and knowledgeable as well, which makes things so much easier. This is truly a 5-star agency." "I love IntelyCare because everything has been easy from the application process until now. There has never been a question unanswered, and everyone is always happy to help with whatever I needed. They always advocate on our behalf. I am so grateful to be an IntelyPro." Job Responsibilities Providing high-quality RN care in post-acute facilities Reviewing various care options with the medical team, residents, and their family members Coordinating with clinical teams to develop individualized care plans Being accountable to follow and adhere to resident care plans Administering appropriate medications and treatments to residents Drawing fluids as needed for labs and testing Using and monitoring medical equipment and devices to ensure effectiveness Training and supervising nursing professionals and other care staff consistent with scope of practice guidelines Promoting staff compliance with all applicable laws, regulations, facility policies, and nursing standards of care Documenting all relevant data to include vital signs, nursing interventions and responses, and resident histories Assisting staff members with incident investigations and the development of care best practices Qualifications and Skills Current Ohio state license to practice as a Registered Nurse (RN) 6 months of experience (in an RN or related role) Completion of an approved nursing program High level of organizational skills Demonstrated ability to effectively communicate across medical and nursing teams Ability to lift at least 50 lbs Get the Work-Life Balance You Deserve — and More If you're looking for Registered Nurse (RN) jobs in your area, our team is ready to hear from you. Build your career with a job that doesn't force you to choose between work and your personal life — apply to the team ranked #1 in quality today. We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status. Location: Maineville, Ohio 45039

Full-time

Registered Nurse (RN) – Emergency Room (ER) – Kings Mills Hospital

apartment Bon Secours Mercy Health location_onMason, OH

Thank you for considering a career at Mercy Health! Scheduled Weekly Hours: 36 Work Shift: Nights (United States of America) Mercy Health About Us As a faith-based and patient-focused organization, Mercy Health exists to enhance the health and well-being of all people in mind, body and spirit through exceptional patient care. Success in this goal requires a culture of compassion, collaboration, excellence and respect. Mercy Health seeks people that are committed to our values of compassion, human dignity, integrity, service and stewardship to create an environment where associates want to work and help communities thrive. Registered Nurse (RN) – Emergency Room (ER) – Kings Mills Hospital Shift: 7pm-730am ***RNs could receive a sign-on bonus up to $15,000 with 1 year prior experience in specialty.*** Job Summary: The Emergency Room (ER) Registered Nurse (RN) position is responsible for delivering exceptional nursing care to patients by: Utilizing strong organizational and leadership skills to assess patient status Determining the priority of the patient’s problems and needs Implementing clinical nursing interventions Having a highly diverse skillset Developing and performing patient care plans to enhance and improve outcomes Ensuring a safe and therapeutic environment Essential Functions: Collaborate with the interdisciplinary care team Care for groups of patients in a fast-paced, high intensity setting as part of an interprofessional team focused on achieving the best individual patient and population outcomes Evaluates, updates and revises the plan of care to facilitate achievement of planned and expected outcomes Serves as point of contact for patients' care coordination throughout hospital departments Provides care to a broad spectrum of patients ranging from short-stay to trauma Administer medications in a safe manner consistent with the State of Practice and the organization’s policies and procedures Other duties as assigned Education: Graduate of an accredited Associates degree or Bachelors degree in Nursing Certifications: Current state licensure as a Registered Nurse (RN) BLS Basic Life Support or ACLS Advanced Cardiac Life Support and PALS Pediatric Advanced Life Support (preferred at hire, must obtain from approved source prior to direct patient care; ACLS and PALS required within 6 months of hire) Experience: One (1) year of professional experience practicing as a Registered Nurse (RN) Recent Emergency Department or Critical Care experienced preferred, not required Training: EPIC Electronic Health Record training (preferred, not required) Mercy Health is an equal opportunity employer. As a Mercy Health associate, you’re part of a Misson that matters. We support your well-being – personally and professionally. Our benefits are built to grow with you and meet your unique needs, every step of the way. What we offer • Competitive pay, incentives, referral bonuses and 403(b) with employer contributions (when eligible) • Medical, dental, vision, prescription coverage, HAS/FSA options, life insurance, mental health resources and discounts • Paid time off, parental and FMLA leave, short- and long-term disability, backup care for children and elders • Tuition assistance, professional development and continuing education support Benefits may vary based on the market and employment status. Department: Emergency Department - Kings Mills It is our policy to abide by all Federal and State laws, as well as, the requirements of 41 CFR 60-1.4(a), 60-300.5(a) and 60-741.5(a). Accordingly, a ll applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, genetic information, or protected veteran status, and will not be discriminated against on the basis of disability. If you’d like to view a copy of the affirmative action plan or policy statement for Mercy Health – Youngstown, Ohio or Bon Secours – Franklin, Virginia; Petersburg, Virginia; and Emporia, Virginia, which are Affirmative Action and Equal Opportunity Employer, please email recruitment@mercy.com . If you are an individual with a disability and would like to request a reasonable accommodation as part of the employment selection process, please contact The Talent Acquisition Team at recruitment@mercy.com .