Clinical Documentation Specialist

🕒 June 17

🌾 Iowa – Remote

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⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

🦅 H1B Visa Sponsor

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👻 Ghost score 51%

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Logo of Trinity Health

Trinity Health

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 efforts toward the integrity of clinical documentation as a reviewer, educator and consultant • Facilitate the quality, completeness and accuracy of medical record documentation through extensive record review • Ensure clinical documentation accurately reflects severity of illness, risk of mortality, quality indicators and level of services provided • 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 the 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 wpm

🏖️ Benefits

• Equal Opportunity Employer commitment • Consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law

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