Clinical Documentation Specialist - (Remote)

Trinity Health • Pontiac, MI

3d • Remote

About The Position

Trinity Health Oakland is seeking an experienced Clinical Documentation Specialist (CDS) with a strong clinical background to improve documentation integrity across inpatient care settings. The Clinical Documentation Specialist utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator, and consultant. They facilitate the overall quality, completeness, accuracy, and integrity of medical record documentation through extensive record review. This is a fully remote position with flexible scheduling options and is a full-time benefited position, scheduled for 40 hours per week (1.0 FTE).

Requirements

• Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) OR Advanced degree in nursing or medical field such as APP.
• Must possess one of the following: Current Registered Nurse License in the State of practice, Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS) required, Licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APN) or completion of medical school.

Nice To Haves

• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred.
• Two (2) years’ experience as an inpatient coder preferred or experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN)

Responsibilities

• Achieves appropriate clinical documentation to support the medical necessity and level of services rendered to all patients through extensive interaction with physicians, nursing staff, and other patient caregivers.
• Demonstrates understanding of appropriate clinical documentation to ensure that the severity of illness, risk of mortality, and level of services provided are accurately reflected in the health record.
• Assists in the 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.
• Accurately codes all relevant, appropriate, and compliant working diagnoses codes, establishing a working principal diagnosis and working DRG (MS or APR).
• Collaborates with coding staff to ensure documentation of discharge diagnoses and co-morbidities is a complete reflection of the patient’s clinical status and care.
• Resolves all discrepancies in a courteous manner.

Benefits

• Full benefits package including Medical, Dental, Vision, PTO, Life Insurance, Short and Long-term Disability.
• Benefits effective Day One! No waiting periods.
• Retirement savings plan with employer match.
• Opportunity for growth and advancement throughout Trinity Health
• Tuition Reimbursement

What This Job Offers

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