Clinical Documentation Specialist

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

📋 Description

• Enhance the integrity of documentation across inpatient care environments.

• Lead clinical documentation integrity initiatives as a reviewer, educator, and consultant.

• Conduct thorough reviews of medical records to elevate quality, completeness, accuracy, and integrity.

• Collaborate with physicians, nursing staff, and other patient caregivers to ensure medical necessity and appropriate levels of services.

• Ensure that the severity of illness, risk of mortality, and levels of services are accurately documented in health records.

• Promote the quality, timeliness, and completeness of health records.

• Provide education to physicians and healthcare team members regarding clinical documentation and monitor provider involvement.

• Perform concurrent reviews of selected patient health records.

• Develop compliant clarifications and queries in accordance with Trinity Health procedures.

• Engage with clinical staff on documentation requirements, query requests, and educational opportunities.

• Code relevant and compliant working diagnoses, primary diagnoses, and working DRG (MS or APR).

• Work in partnership with coding staff to ensure that discharge diagnoses and comorbidities accurately depict the patient’s clinical status and care.

• Address and resolve discrepancies in documentation and coding.

⛳️ Requirements

• Preferred certification as a Clinical Documentation Specialist (CCDS) or Documentation Improvement Professional (CDIP).

• A minimum of two years’ experience as an inpatient coder is preferred, or experience in Critical Care, Medical, or Surgical Inpatient Care Nursing as an RN, physician assistant (PA), or nurse practitioner/advanced practice nurse (NP/APN).

• An Associate/Diploma Degree in Nursing or Health Information Technology (HIT), or a higher degree in nursing or a medical field such as APP.

• Must hold one of the following: a current Registered Nurse License in the state of practice; Registered Health Information Administrator (RHIA); Registered Health Information Technician (RHIT); Certified Coding Specialist (CCS); licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APN); or completion of medical school.

• Strong clinical expertise in inpatient care settings.

• Availability for full-time work, totaling 40 hours per week (1.0 FTE).

🏝️ Benefits

• Comprehensive benefits package that includes Medical, Dental, Vision, PTO, Life Insurance, and Short and Long-term Disability.

• Benefits start on Day One with no waiting periods.

• Retirement savings plan with employer matching contributions.

• Opportunities for professional growth and advancement within Trinity Health.

• Tuition Reimbursement.

• Flexible scheduling options.