
Clinical Documentation Specialist
Posted 4 days ago

Posted 4 days ago
This is a fully remote position, open to applicants in Iowa.
• 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.
• 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.
• 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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