documentation consultant

Defense Holdings, Inc.

<div>Defense Holdings, Inc. (DHi) 
Location: Hybrid, Remote (US) 
Employment Type: Full-Time 
Department: Compliance / Documentation 
Reports To: Documentation Manager
Company Overview
Defense Holdings, Inc. (DHi) is a trusted provider of innovative solutions and mission-critical services supporting U.S. defense, federal, and commercial clients. We are committed to operational excellence, integrity, and delivering results that strengthen national security and organizational performance.
At DHi, our people are our greatest asset. We foster a collaborative, performance-driven environment where professionals are empowered to grow, innovate, and make meaningful contributions.
Position Summary
Defense Holdings, Inc. (DHi) is seeking a Remote Documentation Assistant (Technical &amp; Compliance) to support the documentation department in preparing, maintaining, and reviewing technical and compliance documentation while ensuring accuracy and regulatory alignment. The ideal candidate will be highly detail-oriented, analytical, and able to manage documentation processes efficiently.
This role requires strong organizational skills and the ability to communicate with team members effectively.
Key Responsibilities
Billing &amp; Accounts Processing<ul><li>
Prepare, review, and maintain technical and compliance documents in a timely manner.
</li><li>Ensure accurate documentation records and version control updates.
</li><li>Handle internal requests for document updates and revisions.
</li></ul>Compliance &amp; Reporting<ul><li>
Assist in the preparation of compliance reports for management review.
</li><li>Ensure compliance with regulatory policies and documentation standards.
</li><li>Help with audits and support compliance reporting processes.
</li></ul>Cross-Department Coordination<ul><li>
Collaborate with compliance, legal, and operations teams.
</li><li>Ensure documentation procedures align with company policies and industry standards.
</li></ul>Required Qualifications<ul><li>
Associate&rsquo;s or Bachelor&rsquo;s degree in Business, Technical Writing, or related field.
</li><li>2&ndash;4 years of experience in documentation, compliance, or administrative support.
</li><li>Proficiency in Microsoft Office Suite and documentation tools.
</li><li>Strong analytical skills and attention to detail.
</li><li>Ability to manage multiple priorities in a fast-paced environment.
</li></ul>Preferred Qualifications<ul><li>
Experience in government contracting or defense-related compliance.
</li><li>Familiarity with document control systems.
</li></ul>Core Competencies<ul><li>
Accuracy &amp; Attention to Detail: Ensure accuracy in documentation and reporting.
</li><li>Communication Skills: Effectively communicate with team members.
</li><li>Problem-Solving: Address documentation issues and discrepancies proactively.
</li><li>Time Management: Handle multiple tasks efficiently and meet deadlines.
</li></ul>Work Environment<ul><li>
Professional office environment (or hybrid/remote if applicable).
</li><li>May require occasional travel.
</li><li>Must be eligible to work in the United States.
</li><li>Ability to obtain and maintain security clearance may be required.
</li></ul>Compensation &amp; Benefits
Defense Holdings, Inc. (DHi) offers a competitive compensation package including:<ul><li>
Competitive base salary (commensurate with experience)
</li><li>Medical, Dental, and Vision Insurance
</li><li>401(k) with company match
</li><li>Paid Time Off (PTO) and Holidays
</li><li>Life and Disability Insurance
</li><li>Professional development opportunities
</li></ul>Equal Opportunity Employer Statement
Defense Holdings, Inc. (DHi) is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other protected characteristics in accordance with applicable laws.</div>

Documentation Assistant

TriHealth Inc.

<div><div>Join Our Team as a Clinical Documentation Specialist II! 
Join TriHealth as a Clinical Documentation Specialist II and partner with interdisciplinary teams to improve documentation accuracy, support quality outcomes, and elevate patient care. Apply today and be part of a team that is passionate about making a difference. 
We offer career growth opportunities, and a comprehensive benefits package. 
Location:<ul><li>
Remote</li><li>
This position requires in‑person attendance for scheduled onsite meetings; therefore, candidates must be located within the greater Cincinnati area.</li></ul> 
Work Schedule:<ul><li>
Full time</li><li>
Day shift</li><li>
No weekend or holiday rotation required</li></ul> 
Incentives &amp; Benefits:
We offer a comprehensive benefits package, including medical, dental, vision, paid time off, retirement plans, and tuition reimbursement.
https://careers.trihealth.com/what-we-offer/benefits 
Job Requirements:<ul><li>
Bachelor's Degree in Nursing; Business, Education, HIM,</li><li>
CCDS - Certified Clinical Documentation Specialist</li><li>
Registered Nurse</li><li>
Advanced CDI certification if available</li><li>
Computer aptitude including but not limited to electronic medical record clinical documentation software programs, Word, Excel and PowerPoint</li><li>
5-7 years experience Clinical Nursing</li><li>
2-3 years experience Clinical Documentation</li></ul> 
Job Overview:<ul><li>
The Clinical Documentation Specialist II reports to the Clinical Documentation Department Manager. This team member assists with the delivery of clinical documentation strategies within the workplace that positively impact and drive change to attain organizational goals as well as maintain documentation standards as set by government and corporate guidelines, The Clinical Documentation Specialist II requires an advanced level of knowledge and experience for the successful management of clinical education in their specialty area, quality monitoring, documentation review and the ability to communicate this knowledge to team members throughout the organization, including Medical Staff Departments. They will serve as a subject matter experts in their specialty field which includes but is not limited to preparing and presenting a minimum of two educational topics each calendar year for the benefit of the medical staff, APNs, residents and/or team members as well as being responsible for specialty specific orientation to new team members or those who need refreshers. They will participate in peer interviews and leadership opportunities such as serving on committees, leading journal club or conducting a review course for team members interested in certification. This position requires a professional who works well independently but also values team and possesses excellent communication skills.</li></ul> 
Job Responsibilities:<ul><li>
Documentation Improvement - record review rate of at least 98%. Severity clarification rate of at least 25%. DRG shift clarification rate of at least 15%. 
Provides Informal education includes sharing with team members in assigned patient care area, inpatient coding department and clinical documentation team advanced or new strategies for capturing highest level of SOI/ROM, denial prevention, and determining PSIs. Documentation of informal education with physicians, APNs, residents on documentation strategies and their importance.</li></ul><ul><li> 
Maintains specialty certification and pursue advanced CDI certification within 1 year of certification becoming available. A minimum of two formal presentations per year on pertinent advanced CDI topics at monthly team meetings, resident or medical staff meetings.</li></ul><ul><li> 
Participates in department or hospital committees such as Stroke Committee, Task Force, etc., new team member specialty orientation leader or participating as part of the peer interview team. Other options include but are not limited to leading a department journal club or participating in a minimum of 10 hours of approved community service per year.</li></ul> 
Other Job-Related Information:
This position requires excellent verbal and written communication skills as well as proficiency in the electronic medical record, clinical documentation software, word, excel and power point. Expectation is that the Clinical Documentation Specialist 2 will prepare a minimum of two educational topics to be shared with team members at staff meetings and/or physicians at staff meetings on topics related to advanced CDI. 
Working Conditions: 
Climbing - Occasionally 
Concentrating - Consistently 
Continous Learning - Consistently 
Hearing: Conversation - Occasionally 
Interpersonal Communication - Consistently 
Kneeling - Occasionally 
Lifting &lt;10 Lbs - Occasionally 
Lifting 50+ Lbs - Rarely 
Lifting 11-50 Lbs - Occasionally 
Pulling - Occasionally 
Pushing - Frequently 
Reaching - Frequently 
Reading - Consistently 
Sitting - Frequently 
Standing - Frequently 
Stooping - Occasionally 
Thinking/Reasoning - Consistently 
Use of Hands - Consistently 
Color Vision - Consistently 
Walking - Frequently<div> 
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&hellip; 
<ul><li>Welcome everyone by making eye contact, greeting with a smile, and saying &quot;hello&quot;</li><li>Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist</li><li>Refrain from using cell phones for personal reasons in public spaces or patient care areas</li></ul></div><div> 
Excel: ALWAYS&hellip; 
<ul><li>Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met</li><li>Offer patients and guests priority when waiting (lines, elevators)</li><li>Work on improving quality, safety, and service</li></ul></div><div> 
Respect: ALWAYS&hellip; 
<ul><li>Respect cultural and spiritual differences and honor individual preferences.</li><li>Respect everyone&rsquo;s opinion and contribution, regardless of title/role.</li><li>Speak positively about my team members and other departments in front of patients and guests.</li></ul></div><div> 
Value: ALWAYS&hellip; 
<ul><li>Value the time of others by striving to be on time, prepared and actively participating.</li><li>Pick up trash, ensuring the physical environment is clean and safe.</li><li>Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.</li></ul></div><div> 
Engage: ALWAYS&hellip; 
<ul><li>Acknowledge wins and frequently thank team members and others for contributions.</li><li>Show courtesy and compassion with customers, team members and the community</li></ul></div> 
Job Keywords: Registered Nurse, Nurse, Clinical Documentation</div></div>

Clinical Documentation Specialist II

The University of Iowa

<div>The Clinical Documentation Improvement (CDI) program at UI Health Care has an opening for a full-time Clinical Documentation Specialist. The primary purpose of Clinical Documentation Improvement (CDI) is concurrent review of the medical record to increase the accuracy, clarity, and specificity of provider documentation (Association of Clinical Documentation Improvement Specialists, ACDIS).
Clinical Documentation Specialists bridge the gap between the providers and hospital coders to clarify at-risk documentation to ensure accurate claim submission (American Health Information Management Association, AHIMA). CDI chart reviews include:<ul><li>
New acute inpatient admissions to the facility</li><li>
Identifies and re-reviews high priority charts every two days or as needed</li><li>
Retrospective reviews for query identification, documentation clarification, denials, or quality measures.</li><li>
Completes quality reviews focused on CDI quality elements, such as Mortality, Hospital Acquired Conditions (HAC), and other publicly reported patient quality or safety metrics (i.e., AHRQ Patient Safety Indicators)</li></ul>
When provider documentation is illegible, incomplete, imprecise, inconsistent, conflicting, or unreliable the Clinical Documentation Specialist is expected to communicate (i.e., query) with the provider to obtain the necessary information to clarify the medical record (AHIMA, 2014).
The Clinical Documentation Specialist must hold a general proficiency within both the clinical and hospital coding skill sets. The Clinical Documentation Specialist provides the geometric mean length of stay (GMLOS) associated with the working DRG to identify the expected length of stay for acute inpatients.
The successful candidate will have:<ul><li>
A bachelor&rsquo;s degree in nursing or a master&rsquo;s degree in nursing (MNHP or MSN)</li><li>
An Iowa nursing license</li><li>
Three years of recent inpatient nursing experience in a medical-surgical, and/or ICU setting, and/or recent work experience as a Clinical Documentation Specialist, CDI nurse, or healthcare quality professional with specific medical record review experience</li><li>
Must obtain CCDS (Certified Clinical Documentation Specialist) certification within 3 years of hire.</li><li>
Applicants must upload a current resume and a cover letter that clearly address how they meet the listed required and desired qualifications of this position.</li></ul>
Initial training and onboarding will take place at the Healthcare Support Services Building (HSSB), 3231 Ridgeway Drive, located in Coralville, IA 52241. This position is eligible to participate in 100% remote work after the initial training and onboarding has been completed. Remote work must be performed at a location within the state of Iowa and will require a work arrangement form to be completed upon the start of your employment. Per policy, work arrangements will be reviewed annually, and must comply with the remote work program and related policies and the employee travel policy when working at a remote location.
Job Duties and Responsibilities:<ul><li>
Establishes effective and collaborative relationships with members of the hospital community to improve accuracy and completeness of acute inpatient documentation, especially with providers, Health Information Management coding staff, hospital administration, and other patient caregivers.</li><li>
Demonstrate knowledge of MS-DRGs, APR-DRGs, documentation opportunities, clinical documentation requirements, and inpatient quality/safety metrics.</li><li>
Consistently attends huddles or rounds on units, as directed by department leadership.</li><li>
Provides consistent education on clinical documentation opportunities, hospital coding and/or reimbursement issues, as well as performance improvement methodologies to all members of the hospital community.</li><li>
Conduct record reconciliation and communicates effectively with hospital coding staff to assign an appropriate working DRG.</li><li>
Documents appropriately in the 3M&copy; Clinical Documentation Improvement module.</li><li>
Demonstrates an understanding of the importance of capturing all potential secondary diagnosis for coding purposes.</li><li>
Maintains thorough and current knowledge of clinical care and treatment of assigned patient populations to critically assess appropriateness of documentation.</li><li>
Comply with departmental standards regarding attendance, documentation, departmental workflows, continuous quality improvement and statistics, departmental policies and procedures, and the Code of Ethics.</li><li>
Effectively collaborates and respectfully communicates with fellow CDI team members, the hospital coding team, and quality-driven workgroups to ensure appropriate CDI practices and accurate application of coding/documentation principals.</li><li>
Actively participate in office and/or intradepartmental committees.</li><li>
Performs other projects or responsibilities as assigned.</li></ul>
Percent of Time: 100% (full-time)
Work schedule: Some flexibility between the hours of 7:00 AM and 5:00 PM, Monday through Friday.
Location: Initial onboarding and training will be completed at the Healthcare Support Services Building (HSSB), located at 3231 Ridgeway Drive in Coralville, IA 52241. This position is eligible to participate in 100% remote work after the initial training and onboarding has been completed. Remote work must be performed at a location within the state of Iowa and will require a work arrangement form to be completed upon the start of your employment. Per policy, work arrangements will be reviewed annually, and must comply with the remote work program and related policies and the employee travel policy when working at a remote location.
Salary level 5A. Starting salary will be based on applicant qualifications and related/relevant experience. To view the full pay range for salary level 5A: Professional and Scientific Pay Structures | University Human Resources - The University of Iowa.
Benefits Highlights: Fringe benefit package including paid vacation; sick leave; health, dental, life and disability insurance options; and generous employer contributions into retirement plans. Complete information regarding the full benefits package may be viewed at: https://hr.uiowa.edu/benefits.
<div>Required Qualifications:<ul><li>
A bachelor&rsquo;s degree in nursing or a master's degree in nursing (MNHP or MSN) is required.</li><li>
A current license to practice nursing in Iowa is required.</li><li>
Three years of recent (within the last 10 years) of inpatient nursing experience in a medical-surgical, and/or ICU setting, and/or recent work experience as a Clinical Documentation Specialist, CDI nurse, or healthcare quality professional with specific medical record review experience are required.</li><li>
Must obtain CCDS (Certified Clinical Documentation Specialist) certification within 3 years of hire.</li><li>
Professional written and verbal communication skills are required</li><li>
Demonstrates the ability to provide effective education in a variety of styles, including formal presentations.</li><li>
Proficiency with computer software applications (i.e., Microsoft applications) is required</li><li>
Demonstrates excellent interpersonal skills with physicians, nursing staff, and interdisciplinary team members as demonstrated through written and verbal communication is required.</li><li>
Demonstrated organizational, time management and problem-solving skills are required.</li></ul> 
Desired Qualifications:
<ul><li>Experience with performance improvement methodologies</li><li>
Experience improving and/or reviewing hospital quality/safety metrics</li><li>
Experience with data mining and/or data analytics</li><li>
Advanced certification (i.e., CCDS, CDIP, CPHQ)</li></ul>
Application Process:<ul><li>
To be considered for an interview, applicants must upload a current resume and a cover letter that clearly address how they meet the listed required and desired qualifications of this position.</li><li>
Job openings are posted for a minimum of 7 calendar days. Applications will be accepted until 11:59 PM on March 25, or on date of closing.</li><li>
Successful candidates will be required to self-disclose any conviction history and will be subject to a criminal background check.</li><li>
Professional references will be requested at a later step in the recruitment process.</li><li>
This position is not eligible for University of Iowa sponsorship for employment authorization.</li><li>
For questions, contact Heidi Bodensteiner at heidi-bodensteiner@uiowa.edu.</li></ul></div></div>

Clinical Documentation Specialist

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