Clinical Documentation Specialist

This is a fully remote position, open to applicants in Iowa.

📋 Description

• Leverage clinical and coding proficiency to uphold the integrity of clinical documentation in the roles of reviewer, educator, and consultant.

• Enhance the quality, completeness, and accuracy of medical record documentation through thorough record analysis.

• Exhibit knowledge of documentation necessary to accurately depict severity of illness, risk of mortality, quality indicators, and service levels.

• Engage with and educate physicians and members of the healthcare team regarding clinical documentation.

• Oversee provider engagement.

• Perform concurrent evaluations of selected patient health records for legibility, clarity, completeness, consistency, and accuracy.

• Develop compliant clarifications/queries in accordance with Trinity Health documentation integrity procedures.

• Integrate the Trinity Mission, Vision, and Values into behaviors, practices, standards, policies, procedures, and decision-making.

⛳️ Requirements

• Associate/Diploma Degree in Health Information Technology (HIT) or an advanced degree in nursing (NP, APN) or as a Physician Assistant.

• If a college degree is not held, a minimum of three (3) years’ experience as an inpatient coder or documentation specialist is required.

• Preferred certifications include: RN, RHIA, RHIT, CCS, CCDS, or CDIP.

• Experience in critical care, medical or surgical inpatient nursing as an RN, PA, NP, APN, or inpatient coder is preferred.

• Exceptional communication, interpersonal, collaboration, and relationship-building abilities.

• Strong critical thinking capabilities and the ability to integrate knowledge effectively.

• Skills in prioritization and organization.

• Proficiency in using standardized desktop and Windows-based computer systems.

• Data entry and typing skills of at least 30 wpm.

🏝️ Benefits

• Full-time remote position.

• Day shift.

• Equal Opportunity Employer.