Clinical Documentation Specialist

🔥 1 hour ago

🏈 Ohio – Remote

🏈 Ohio – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 10%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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 efforts toward the integrity of clinical documentation as reviewer, educator, and consultant • Conduct concurrent reviews of selected patient records for legibility, clarity, completeness, consistency, and precision • Ensure documentation accurately reflects severity of illness, risk of mortality, medical necessity, and services provided • 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 • Use computer systems effectively and maintain records of reviews, queries, and physician responses • Participate in performance improvement activities, in-service programs, staff meetings, and committees • Report actual or potential wrongdoing and perform other assigned duties

🎯 Requirements

• 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, 3 or more years of experience as an inpatient coder or clinical documentation specialist • RHIA, RHIT, CCDS, CDIP, or CCS certification considered in lieu of an RN • Experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, PA, NP/APN, or as an inpatient coder preferred • Clinical and coding expertise • Ability to conduct extensive medical record review • Knowledge of clinical documentation requirements, coding definitions, query standards, and policies • Effective written and verbal communication with physicians and healthcare team members • Proficiency with computer systems and maintaining review/query records

🏖️ Benefits

• Medical, dental, and vision 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 access for eligible colleagues • Diversity, Equity, and Inclusion Colleague Resource Groups