Clinical Documentation Specialist

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

📋 Description

• Lead initiatives to ensure the integrity of clinical documentation by serving as a reviewer, educator, and consultant.

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

• Exhibit proper clinical documentation practices to ensure that severity of illness, risk of mortality, quality indicators, and service levels are accurately represented.

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

• Oversee provider participation and engagement.

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

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

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

⛳️ Requirements

• Associate/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, a minimum of 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.

• Preferred experience in critical care, medical or surgical inpatient nursing as an RN, PA, NP, APN, or inpatient coder.

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

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

• Proficient in prioritization and organizational skills.

• Competence 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.

• Dedication to person-centered care principles.