Clinical Documentation Specialist Remote

Trinity Health•Davenport, IA

3d•Remote

About The Position

MercyOne Genesis is seeking a Full-Time Remote Clinical Documentation Specialist. This position (80 Hours Biweekly) utilizes clinical and coding expertise to ensure the integrity of clinical documentation. The role involves reviewing medical records for quality, completeness, and accuracy, and educating healthcare providers. The specialist will conduct concurrent reviews, formulate clarifications/queries, and ensure documentation accurately reflects the severity of illness, risk of mortality, quality indicators, and level of services provided.

Requirements

Associate degree in Nursing or HIT.
In absence of degree, 3 years' experience as an inpatient code or clinical documentation specialist.
Demonstrated ability to use standardized desktop and Windows based computer system.
Data entry and typing skills at minimum 30 wph.

Nice To Haves

RN, RHIA, RHIT, CCS, CCDS or CDIP certifications.
Experience in critical care, medical or surgical inpatient care nursing as an RN, PA, NP, APN or inpatient coder.
Excellent communication, interpersonal, collaboration and relationship building skills.
Strong critical thinking skills, and ability to integrate knowledge.
Prioritization and organization skills.

Responsibilities

Utilizes clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant.
Facilitates the overall quality, completeness and accuracy of medical record documentation through extensive record review.
Demonstrates understanding of appropriate clinical documentation to ensure the severity of illness, risk of mortality, quality indicators and level of services provided are accurately reflected in the health record.
Communicates with and educates physicians and all other members of the healthcare team in clinical documentation and monitors provider engagement.
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.