Clinical Documentation Specialist

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

📋 Description

• Lead initiatives aimed at enhancing clinical documentation integrity through roles as a reviewer, educator, and consultant.

• Promote the quality, completeness, and accuracy of medical record documentation by conducting thorough record reviews.

• Ensure that documentation correctly represents the severity of illness, risk of mortality, quality indicators, and the level of services rendered.

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

• Oversee provider engagement activities.

• Perform concurrent reviews of selected patient health records to assess legibility, clarity, completeness, consistency, and accuracy.

• Develop compliant clarifications and queries in accordance with Trinity Health's documentation integrity protocols.

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

⛳️ Requirements

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

• In the absence of a college degree, 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 or medical/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 skills with the capability to integrate knowledge effectively.

• Skills in prioritization and organization.

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

• Data entry and typing proficiency of at least 30 words per minute.

🏝️ Benefits

• Commitment to being an Equal Opportunity Employer.

• Consideration for employment without regard to protected characteristics under federal, state, or local law.