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 works 80 hours biweekly and requires an AA degree in Nursing or HIT. If a degree is not present, 3 years of experience as an inpatient coder or a clinical documentation specialist is required. The role involves ensuring clinical documentation accurately reflects the severity of illness, risk of mortality, quality indicators, and level of services provided. Responsibilities include communicating with and educating healthcare providers, conducting concurrent reviews of patient records, and formulating compliant clarifications/queries.

Requirements

• 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.
• 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 integrate knowledge.
• Prioritization and organizations skills required.

Responsibilities

• 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