Clinical Document Specialist

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve

Responsible for facilitating improvement in the overall quality, completeness, and accuracy of medical record documentation.

Roles and Responsibilities 

• Assesses and monitors clinical information within the patient’s medical record on a concurrent basis.
• Identifies clinical opportunities for documentation improvement.
• Ensures clinical documentation accurately reflects the appropriate severity and meets regulatory guidelines by interactions and clarifications with physicians, nursing and coding staff.
• Educates physicians and nursing on Clinical Documentation Improvement (CDI) strategies.
• Documents assessments and physician clarifications within Guide software.
• Presents CDI data, regulatory updates and/or other CDI educational material at various Medical Staff meetings.
• Understands payor systems and impacts.
• Works autonomously with little direction.
• Works well with diverse opinions, religious and cultural ideals and values.
• Maintains knowledge of equipment and continuously learns new technology and is able to trouble shoot equipment, report malfunctioning equipment and ensure its repair and return to service.

Minimum Qualifications

• Active registration for Registered Nurse - Board of Nursing, State of Iowa.
• Minimum of five years’ experience in Medical/Surgical, PCU, CCU, Cardiac or ED nursing.
• Bachelor of Science in Nursing degree preferred at hire; otherwise must maintain agreed upon timeframe for completion.
• Must possess leadership qualities including time management, verbal and written communication skills, listening skills, problem solving, decision making, priority setting, work delegation, work organization, and customer service focus.
• Must be able to demonstrate basic computer skills in a Windows environment.
• Possesses working knowledge of personal computer using programs such as Word, Excel, Powerchart, etc.
• Must be comfortable operating in a collaborative, shared leadership environment.
• Must possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission and vision, goals, and values of Trinity Health.