Clinical Documentation Specialist (CDI -RN) - (Remote)

Trinity Health • Livonia, MI

1d • Hybrid

About The Position

The Clinical Documentation Specialist utilizes advanced clinical and coding expertise to ensure the integrity of clinical documentation. This role involves reviewing medical records, educating physicians and healthcare teams, and acting as a consultant to facilitate overall quality, completeness, accuracy, and integrity of documentation. The specialist interacts extensively with healthcare professionals to achieve appropriate clinical documentation that supports code assignment, medical necessity, severity of illness, risk of mortality, and the level of services provided to patients. They also contribute to the development and delivery of educational programs for providers.

Requirements

• Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) or an Advanced degree in nursing or medical field such as MD, DO, NP/APN or PA.
• In the absence of a college degree, must have 3 or more years’ experience as an inpatient coder or clinical documentation specialist.
• Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills.
• Strong critical thinking skills and ability to integrate knowledge.
• Prioritization and organizational skills required.
• Effective presentation/facilitation skills to accomplish educational goals for all members of the healthcare team.
• Demonstrated ability to use a standard desktop and Windows based computer system, including a basic understanding of email, internet and computer navigation.
• Ability to use other software as required to perform the essential functions on the job.
• Data entry skills and typing skills at minimum 30 wpm.
• Must be comfortable operating independently and in a collaborative environment.
• Must possess a personal presence that is characterized by a sense of honesty, integrity and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals and values of Trinity Health.

Nice To Haves

• Current Registered Nurse License
• Registered Health Information Administrator (RHIA)
• Registered Health Information Technician (RHIT)
• Certified Coding Specialist (CCS)
• Certified Clinical Documentation Specialist (CCDS)
• Certified Documentation Improvement Professional (CDIP)
• Experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), medical school graduate or as an inpatient coder
• Experience with databases, spreadsheet software and presentation software

Responsibilities

• Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, standards, policies, procedures and decisions.
• Demonstrates understanding of appropriate clinical documentation to ensure that the severity of illness, risk of mortality, quality indicators and level of services provided are accurately reflected in the health record.
• Assists in 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.
• Codes all relevant, appropriate and compliant working diagnoses codes, establishing a working principle diagnosis and working DRG (MS or APR).
• Collaborates with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care.
• Resolves all discrepancies in a courteous manner.
• Demonstrates expertise in problem-solving skills based on theoretical knowledge, clinical experience and sound judgement and serves as a professional role model by demonstrating desirable practice behaviors.
• Leverages the functions of 3M/360 for entering data related to CDI efficiencies and effectiveness.
• Performs other duties as assigned by leadership.
• Maintains a working knowledge of applicable Federal, State and local laws and regulations, accrediting agencies, Trinity Health’s Organizational Integrity Program, Standards of Conduct, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 251-500 employees