Clinical Documentation Specialist

🔥 1 hour ago

🏈 Ohio – Remote

🏈 Ohio – Remote

⏱ Part Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

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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

• Conduct concurrent reviews of selected patient records for legibility, clarity, completeness, consistency, and precision of clinical documentation. • Ensure documentation accurately reflects severity of illness, risk of mortality, 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. • Maintain records of completed reviews, queries, and physician responses using computer systems. • Participate in performance improvement activities, in-service programs, staff meetings, and committees as requested. • Promote workplace safety, relationship-based care, professional growth, and organizational integrity. • Perform other duties as assigned.

🎯 Requirements

• Must possess an Associate/Diploma Degree in Nursing, Health Information Technology (HIT), an advanced degree in nursing (NP/APN), or be a 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. • Must work 4 hours a day, 5 days a week, Monday–Friday. • Meets population-specific and department competencies. • Utilizes computer systems effectively and maintains 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. • Mount Carmel offers DailyPay - if you’re hired as an eligible colleague, you’ll be able to see how much you’ve made every day and transfer your money any time before payday. • Opportunity to join Diversity, Equity, and Inclusion Colleague Resource Groups.

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