Clinical Documentation Specialist

🕒 July 9

🇺🇸 United States – Remote

⏰ Full 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

• Direct efforts toward the integrity of clinical documentation as reviewer, educator and consultant • Facilitate the quality, completeness, accuracy and integrity of medical record documentation through extensive record review • Interact with physicians and healthcare team members to achieve appropriate clinical documentation supporting code assignment, medical necessity, severity of illness, risk of mortality and level of services • Participate in developing and delivering education for providers and healthcare team members • Conduct concurrent reviews of selected patient health records for legibility, clarity, completeness, consistency and precision • Formulate compliant clarifications/queries according to Trinity Health documentation integrity procedures • Accurately code relevant and compliant working diagnoses, working principal diagnosis and working DRG • Collaborate with coding staff to ensure discharge diagnoses and comorbidities reflect the patient’s clinical status and care • Resolve documentation discrepancies courteously • Use 3M/360 for CDI efficiency and effectiveness data entry • Perform other duties assigned by leadership • Maintain knowledge of applicable laws, regulations, accrediting requirements and Trinity Health policies

🎯 Requirements

• Full time, Monday through Friday, day shift • Associate/Diploma Degree in Nursing or Health Information Technology, or advanced degree in nursing or a medical field such as NP/APN or PA • One of the following required: current Registered Nurse license in the state of practice, RHIA, RHIT, CCS, PA licensure, NP/APN licensure, or completion of medical school • Two years of critical care, medical or surgical inpatient care nursing, or relevant physician assistant, nurse practitioner, medical school graduate or inpatient coding experience preferred • CCDS or CDIP certification preferred • Excellent verbal and written communication, interpersonal, collaboration and relationship-building skills • Strong critical thinking and knowledge-integration skills • Prioritization and organizational skills • Presentation/facilitation skills for healthcare-team education • Ability to use Windows-based desktop systems, email, internet and computer navigation • Ability to use required software; database, spreadsheet and presentation software experience preferred • Accurate data-entry and typing skills of at least 30 wpm • Ability to work independently and collaboratively • Current knowledge of applicable Federal, State and local laws, regulations, accrediting agencies and organizational policies

🏖️ Benefits

• Equal Opportunity Employer • Mission- and values-based workplace • Compassionate, person-centered care environment