Clinical Documentation Specialist

🔥 12 hours ago

🌾 Iowa – Remote

🌾 Iowa – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

👻 Ghost score 10%

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Trinity Health

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

🤝 Non-profit

🏨 Hospitality

🔥 Funding within the last year

💰 $20k Grant - Trinity Health on 2025-10

Healthcare • Non-profit • Hospitality

Trinity Health is one of the largest not-for-profit, faith-based healthcare systems in the United States. With approximately 127,000 colleagues and over 38,300 physicians and clinicians, it provides a wide range of medical services and care to diverse communities across 26 states. The organization emphasizes its mission-driven, faith-based values, community impact, employee benefits, and career opportunities including travel nursing through its FirstChoice program. Headquarters are listed in Livonia, Michigan. Trinity Health focuses on patient care, community health, and supporting a large workforce of clinical and non-clinical staff.

📋 Description

• Utilize clinical and coding expertise to direct efforts toward clinical documentation integrity as reviewer, educator and consultant • Facilitate the quality, completeness and accuracy of medical record documentation through extensive record review • Demonstrate appropriate clinical documentation so severity of illness, risk of mortality, quality indicators and level of services are accurately reflected in the health record • Communicate with and educate physicians and healthcare team members on clinical documentation • Monitor provider engagement • Conduct concurrent reviews of selected patient health records for legibility, clarity, completeness, consistency and precision • Formulate compliant clarifications/queries following Trinity Health's documentation integrity procedures • Incorporate and demonstrate Trinity Mission, Vision and Values in behaviors, practices, standards, policies, procedures and decisions

🎯 Requirements

• Must possess an 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 • Preferred Certifications: 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 preferred • Excellent communication, interpersonal, collaboration and relationship building skills • Strong critical thinking skills and ability to integrate knowledge • Prioritization and organization skills required • Demonstrated ability to use standardized desktop and Windows based computer system • Data entry and typing skills at minimum 30 wph

🏖️ Benefits

• Equal Opportunity Employer commitment • Consideration regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other status protected by federal, state, or local law