Clinical Documentation Specialist

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

📋 Description

• Exemplify the Trinity Mission, Vision, and Values through behaviors, 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.

• Educate and communicate with physicians and healthcare team members regarding clinical documentation.

• Oversee provider engagement.

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

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

⛳️ 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 of 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 care nursing as an RN, PA, NP, APN, or inpatient coder is preferred.

• Outstanding communication, interpersonal, collaboration, and relationship-building skills.

• Strong critical thinking abilities and capability to integrate knowledge effectively.

• Proficient prioritization and organizational skills.

• Capability to use standardized desktop and Windows-based computer systems.

• Data entry and typing skills at a minimum of 30 words per minute.

🏝️ Benefits

• Full-time employment.

• Day shift schedule.

• Opportunity for remote work.