Clinical Documentation Specialist

🕒 July 17

🚗 Michigan – Remote

🚗 Michigan – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

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👻 Ghost score 49%

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Trinity Health

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

📚 Education

🤝 Non-profit

Healthcare • Education • Non-profit

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.

📋 Description

• Direct clinical documentation integrity efforts as a reviewer, educator, and consultant • Facilitate the quality, completeness, accuracy, and integrity of medical record documentation through extensive record review • Interact with physicians, nursing staff, and other patient caregivers to achieve appropriate clinical documentation supporting medical necessity and level of services • Ensure severity of illness, risk of mortality, and level of services are accurately reflected in the health record • Support the quality, timeliness, and completeness of health records, provider communication, and quality outcomes • Serve as a resource for appropriate clinical documentation • Communicate with and educate physicians and healthcare team members regarding clinical documentation • Monitor provider engagement and identify learning opportunities • Conduct concurrent reviews of selected patient health records for legibility, clarity, completeness, consistency, and precision • Formulate compliant clarifications and queries according to Trinity Health documentation integrity procedures • Interact with clinical staff regarding compliant documentation requirements, query requests, and educational opportunities • Code relevant, appropriate, and compliant working diagnosis codes, including 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 discrepancies courteously

🎯 Requirements

• Experienced Clinical Documentation Specialist with a strong clinical background improving documentation integrity across inpatient care settings • Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred • Two (2) 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) • Must possess an Associate/Diploma Degree in Nursing or Health Information Technology (HIT), or an advanced degree in nursing or a medical field such as APP • Must possess one of: 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 • Ability to perform extensive medical record review • Knowledge of clinical documentation integrity, coding, medical necessity, severity of illness, risk of mortality, and level of services • Knowledge of compliant documentation clarification/query procedures • Ability to accurately code relevant and compliant working diagnoses, principal diagnosis, and working DRG (MS or APR) • Ability to collaborate with physicians, nurses, ancillary staff, and coding staff

🏖️ 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 • Full-Time benefited position