Clinical Documentation Specialist

🔥 0 minutes ago

🚗 Michigan – Remote

🚗 Michigan – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

🏥📝 Medical Writer

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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

• Improve documentation integrity across inpatient care settings • Direct clinical documentation integrity efforts as reviewer, educator, and consultant • Review medical records extensively to improve quality, completeness, accuracy, and integrity • Interact with physicians, nursing staff, and other patient caregivers to support medical necessity and level of services • Ensure severity of illness, risk of mortality, and level of services are accurately reflected in health records • Support health record quality, timeliness, and completeness • Educate physicians and healthcare team members on clinical documentation and monitor provider engagement • Conduct concurrent reviews of selected patient health records • Formulate compliant clarifications and queries according to Trinity Health procedures • Interact with clinical staff regarding documentation requirements, query requests, and educational opportunities • Code relevant and compliant working diagnoses, working principal diagnosis, and working DRG (MS or APR) • Collaborate with coding staff to ensure discharge diagnoses and comorbidities reflect the patient’s clinical status and care • Resolve documentation and coding discrepancies

🎯 Requirements

• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred • Two years’ experience as an inpatient coder preferred, or experience in Critical Care, Medical or Surgical Inpatient Care Nursing as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN) • Associate/Diploma Degree in Nursing or Health Information Technology (HIT), or advanced degree in nursing or a medical field such as APP • Must possess one of the following: current Registered Nurse License in the State of practice; Registered Health Information Administrator (RHIA); Registered Health Information Technician (RHIT); Certified Coding Specialist (CCS); licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APN); or completion of medical school • Strong clinical background in inpatient care settings • Full-time availability for 40 hours per week (1.0 FTE)

🏖️ Benefits

• Full benefits package including Medical, Dental, Vision, PTO, Life Insurance, Short and Long-term Disability • Benefits effective Day One with no waiting periods • Retirement savings plan with employer match • Opportunity for growth and advancement throughout Trinity Health • Tuition Reimbursement • Flexible scheduling options