Clinical Documentation Specialist

🔥 0 minutes 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

• Direct efforts toward the integrity of clinical documentation 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 • 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 Trinity Mission, Vision and Values into behaviors, practices, standards, policies, procedures and decisions

🎯 Requirements

• Associate/Diploma Degree in Health Information Technology (HIT) or advanced degree in nursing (NP, APN) or Physician Assistant • In absence of a college degree, three (3) years' experience as an inpatient code or clinical documentation specialist • Preferred certifications: RN, RHIA, RHIT, CCS, CCDS or CDIP • Experience 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 • Ability to use standardized desktop and Windows-based computer systems • Data entry and typing skills of at least 30 wpm

🏖️ Benefits

• Equal Opportunity Employer commitment • Person-centered care commitment