Clinical Documentation Specialist

Trinity Health
July 28, 2022
United States
Job Type
Work Setting


Utilizes advanced knowledge and clinical expertise to direct efforts toward the improvement of clinical documentation and quality improvement through the roles of educator and consultant. Assists with facilitating improvement in the overall quality, completeness, and accuracy of medical record documentation to improve key clinical processes and outcomes. Through extensive interaction with physicians, nursing staff, and other patient caregivers, achieves appropriate clinical documentation to support the medical necessity and level of services rendered to all patients. Assists with development and delivery of education for all members of the patient care team on documentation guidelines, issues on an ongoing basis.

Essential Functions and Responsibilities

Provides technical assistance to appropriate service lines performing quality activities including, but not limited to:

- Participating in development and design of improvement activities and standards

- Participating in design of data collection tools and procedures, including planning, measuring and

assessing the effect of improvement activities

- Analyzing, collection and tabulation go appropriate primary and secondary sources of importation.

- Displaying data in a meaningful and useful format.

- Attending meetings to assist in the interpretation of quality improvements studies

  • Utilizes advanced knowledge of functional health patterns physiology, pathophysiology, and psycho sociology in documentation efforts and other projects related to Outcomes Management.
  • Demonstrates expertise in problem-solving skills based on theoretical knowledge, clinical experience and sound judgment and serves as a professional role model by demonstrating desirable practice behaviors.
  • Serves as a resource for clinical documentation and provides support to associates regarding complex patient issues and the impact on clinical documentation needs; provides consultative services to medical and nursing staff related to documentation and core clinical indicators
  • Establishes collaborative practice and maintains open communication with other nursing personnel, physicians and health care professionals regarding clinical documentation.
  • Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with physician have been recorded in the patient’s chart.
  • Facilitates the acquisition and application of clinical, theoretical and financial knowledge and decision-making skills of department staff, physicians, and other health care provides.
  • Assesses learning needs, designs, implements and evaluates systems/processes for health care providers to improve patient outcomes.
  • Evaluates and integrates appropriate research findings into clinical documentation practices as appropriate.
  • Demonstrates continuing expertise in data management and analysis. Entering data into a web-based program. Currently we use Quantros and Midas.


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