Trinity Health
Description
The Clinical Documentation Specialist utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant. This position may be fully remote.
Roles and Responsibilities
- Ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record.
- Assist in overall quality, timeliness and completeness of the health record to ensure appropriate data, provider communication and quality outcomes.
- Conduct concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency and precision of clinical documentation.
- Leverage the functions of 3M/360 for entering data.
- Collaborate with coding staff to ensure documentation of discharge diagnoses and co-morbidities are complete.
Minimum Qualifications
- Applicants for this position must be authorized to work for any employer in the U.S. We are unable to sponsor an employment visa for this position.
- Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred.
- Two (2) years experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), medical school graduate or as an inpatient coder preferred.
Must possess one of the below
- 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.