Clinical Documentation Specialist

🔥 14 minutes ago

🏈 Ohio – Remote

🏈 Ohio – 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

💰 $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

• Conduct concurrent reviews of selected patient records for legibility, clarity, completeness, consistency, and precision of clinical documentation • Ensure clinical documentation accurately reflects severity of illness, risk of mortality, services provided, medical necessity, and level of services rendered • Serve as a resource on appropriate clinical documentation • Communicate documentation discrepancies and coding definitions to physicians in writing and verbally • Conduct one-to-one educational sessions with physicians and healthcare team members • Collaborate with physicians, patient care services, case management, coding specialists, and other healthcare disciplines • Utilize computer systems and maintain records of completed reviews, queries, and physician responses • Participate in performance improvement activities, in-service programs, staff meetings, and committees • Support professional growth and knowledge of care documentation requirements • Promote service excellence, workplace safety, relationship-based care, and organizational integrity • Perform other duties as assigned

🎯 Requirements

• Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT), or an Advanced degree in nursing (NP/APN) or Physician Assistant • In the absence of a college degree, must have 3 or more years’ experience as an inpatient coder or clinical documentation specialist • RHIA, RHIT, CCDS, CDIP, or CCS will be considered in lieu of a RN • Experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), or as an inpatient coder preferred • Meets population specific and all other competencies according to department requirements • Must understand clinical documentation requirements, coding definitions, query standards, and applicable policies • Must effectively use computer systems and maintain records of reviews, queries, and physician responses

🏖️ Benefits

• Competitive compensation and benefits packages including medical, dental, and vision with coverage starting on day one • Retirement savings account with employer match starting on day one • Generous paid time off programs • Employee recognition programs • Tuition/professional development reimbursement • Relocation assistance (geographic and position restrictions apply) • Discounted tuition and enrollment opportunities at the Mount Carmel College of Nursing • Employee Referral Rewards program • DailyPay for eligible colleagues • Diversity, Equity, and Inclusion Colleague Resource Groups