Clinical Documentation Specialist

Posted 4 days ago

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

📋 Description

• Exemplify the Mission, Vision, and Values of Trinity through actions, practices, standards, policies, procedures, and decision-making.

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

• Engage in communication and education with physicians and healthcare team members regarding clinical documentation.

• Oversee provider engagement.

• Conduct 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 procedures.


⛳️ Requirements

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

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

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

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

• Exceptional communication, interpersonal, collaboration, and relationship-building skills are essential.

• Strong critical thinking abilities and the capacity to integrate knowledge are required.

• Skills in prioritization and organization are necessary.

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

• Data entry and typing skills of at least 30 words per minute are required.


🏝️ Benefits

• Full-time remote position.

• Equal Opportunity Employer.

• Consideration given without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

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