Clinical Documentation Specialist Remote

Trinity Health • Davenport, IA

2d • Remote

About The Position

This is a full-time, remote position (80 Hours Biweekly) at MercyOne Genesis. The Clinical Documentation Specialist utilizes clinical and coding expertise to ensure the integrity of clinical documentation. This role involves reviewing medical records to ensure the quality, completeness, and accuracy of documentation, reflecting the severity of illness, risk of mortality, quality indicators, and level of services provided. The specialist will also communicate with and educate physicians and other healthcare team members on clinical documentation and monitor provider engagement. Concurrent reviews of patient health records will be conducted to address legibility, clarity, completeness, consistency, and precision of documentation, 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
• Experienced 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

• 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 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