Clinical Documentation Specialist Remote

Trinity Health • Davenport, IA

3d • Remote

About The Position

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. Essential Functions: Knows, understands, incorporates and demonstrates the Trinity Mission, Vision and Values in behaviors, practices, standards policies procedures and decisions. 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 member 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. Our Commitment Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are 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 any other status protected by federal, state, or local law. Trinity Health is one of the largest not-for-profit, faith-based health care systems in the nation. Together, we’re 121,000 colleagues and nearly 36,500 physicians and clinicians caring for diverse communities across 27 states. Nationally recognized for care and experience, our system includes 101 hospitals, 126 continuing care locations, the second largest PACE program in the country, 136 urgent care locations, and many other health and well-being services. Based in Livonia, Michigan, in fiscal year 2023, we invested $1.5 billion in our communities through charity care and other community benefit programs. For more information, visit http://www.trinity-health.org. You can also follow Trinity Health on LinkedIn.

Requirements

• Must possess an Associate/Diploma Degree in Health Information Technology (HIT) or Advanced degree in nursing (NP, APN) or Physician Assistant.
• In absence of college degree, must have three (3) years' experience as an inpatient code or documentation specialist.
• Excellent communication, interpersonal, collaboration and relationship building skills.
• Strong critical thinking skills, and ability integrate knowledge.
• Prioritization and organizations skills required.
• 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
• Experienced in critical care, medical or surgical inpatient care nursing as an RN, PA, NP, APN or inpatient coder preferred

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.
• Knows, understands, incorporates and demonstrates the Trinity Mission, Vision and Values in behaviors, practices, standards policies procedures and decisions.
• 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 member 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees