Clinical Documentation Improvement Specialist

Trinity Health • Langhorne, PA

1d • Remote

About The Position

Trinity Health Mid-Atlantic is seeking experienced Full-time Clinical Documentation Specialists to join our team! Schedule: Full-time (Remote) / Monday - Friday / No weekends! The Clinical Documentation Improvement Specialist utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant. The CDI Specialist facilitates the overall quality, completeness, accuracy and integrity of medical record documentation through extensive record review.

Requirements

• Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT).
• In the absence of a college degree, must have 3 or more years’ experience as an inpatient coder or clinical documentation specialist.

Nice To Haves

• Preferred Certification as a RN, RHIA, RHIT, CCS, CCDS or CDIP
• Previous CDI experience required, preferably in the acute care setting

Responsibilities

• Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, standards, policies, procedures and decisions
• Demonstrates understanding of appropriate clinical documentation to ensure that the severity of illness, risk of mortality, quality indicators and level of services provided are accurately reflected in the health record.
• Assists in overall quality, timeliness and completeness of the health record to ensure appropriate data, provider communication and quality outcomes.
• Serves as a resource for appropriate clinical documentation.
• Communicates with and educates physicians and all other members of the healthcare team regarding clinical documentation and monitors provider engagement.
• Identifies learning opportunities for healthcare providers.
• Conducts concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency and precision of clinical documentation.
• Formulates compliant clarifications/queries following Trinity Health’s documentation integrity procedures.
• Interacts with physicians, nurses and ancillary staff regarding compliant documentation requirements, clarification/query requests and educational opportunities.
• Codes all relevant, appropriate and compliant working diagnoses codes, establishing a working principle diagnosis and working DRG (MS or APR).
• Collaborates with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care.
• Resolves all discrepancies in a courteous manner.
• Demonstrates expertise in problem-solving skills based on theoretical knowledge, clinical experience and sound judgement and serves as a professional role model by demonstrating desirable practice behaviors.
• Leverages the functions of 3M/360 for entering data related to CDI efficiencies and effectiveness.
• Performs other duties as assigned by leadership.
• Maintains a working knowledge of applicable Federal, State and local laws and regulations, accrediting agencies, Trinity Health’s Organizational Integrity Program, Standards of Conduct, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.

Benefits

• Medical, Dental, & Vision Coverage (Effective First day of Hire)
• Retirement Savings Program
• Paid Time Off
• Tuition Reimbursement
• Free Parking

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree