Clinical Documentation Specialist

3 hours ago

🚗 Michigan – Remote

Although this job is listed in Michigan, this company may be open to hiring remote in other states.

💵 $36 - $54 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

🦅 H1B Visa Sponsor

Apply Now

Receive Emails with Similar Jobs

Trinity Health

WebsiteLinkedInAll Job Openings

Education • Non-profit • Social Impact

Trinity Health is a Christian K-12 educational institution located in Wichita, Kansas, dedicated to providing a Christ-centered education that nurtures spiritual growth and academic excellence. The academy emphasizes the importance of faith in students' lives, integrating spiritual development with rigorous academic programs and a broad array of extracurricular activities, including athletics and fine arts. Trinity Health fosters a supportive community where teachers and families collaborate to help students develop a personal relationship with Jesus Christ and excel in their studies.

10,000+ employees

📚 Education

🤝 Non-profit

🌍 Social Impact

📋 Description

• Utilizes advanced 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, accuracy and integrity of medical record documentation through extensive record review. • Achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients. • Participates in the development and delivery of education for providers and members of the healthcare team. • Communicates with and educates physicians and all other members of the healthcare team regarding 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. • 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. • 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.

🎯 Requirements

• Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) or related education and experience. • Current Registered Nurse License in the State of practice, Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP). • Two (2) years experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, related field, or as an inpatient coder preferred. • 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. • Experience with databases, spreadsheet software and presentation software preferred. • 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.

🏖️ Benefits

• Health insurance • Retirement plans • Paid time off • Flexible work arrangements • Professional development