Clinical Documentation Specialist
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Job Description
Remote Clinical Documentation Specialist supporting Trinity Health’s inpatient documentation integrity. Reviewing records, educating providers, and formulating compliant clinical queries.
Responsibilities:
- Direct efforts toward clinical documentation integrity as a reviewer, educator and consultant
- Facilitate the quality, completeness and accuracy of medical-record documentation through extensive record review
- Ensure documentation accurately reflects severity of illness, risk of mortality, quality indicators and level of services provided
- Communicate with and educate physicians and healthcare-team members on clinical documentation
- Monitor provider engagement
- Conduct concurrent reviews of selected patient health records for legibility, clarity, completeness, consistency and precision
- Formulate compliant clarifications/queries following Trinity Health's documentation integrity procedures
- Incorporate Trinity Mission, Vision and Values into behaviors, practices, standards, policies, procedures and decisions
Requirements:
- Associate/Diploma Degree in Health Information Technology (HIT), or advanced degree in nursing (NP, APN), or Physician Assistant
- In absence of a college degree, three (3) years' experience as an inpatient coder or documentation specialist
- Preferred certifications: RN, RHIA, RHIT, CCS, CCDS or CDIP
- Experience in critical care, medical or surgical inpatient care nursing as an RN, PA, NP, APN or inpatient coder preferred
- Excellent communication, interpersonal, collaboration and relationship-building skills
- Strong critical-thinking skills and ability to integrate knowledge
- Prioritization and organization skills
- Ability to use standardized desktop and Windows-based computer systems
- Data entry and typing skills of at least 30 wpm
Benefits:
- Equal Opportunity Employer commitment
- Consideration for employment without regard to protected characteristics under federal, state, or local law
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