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Trinity Health

We are one of the largest not-for-profit, faith-based health care systems in the nation.

Clinical Documentation Specialist

Medical writerMedical writerFull TimeRemoteSeniorTeam 10,001+H1B SponsorCompany SiteLinkedIn

Location

Iowa

Posted

1 day ago

Salary

Not specified

Seniority

Senior

Associate Degree3 yrs expExperience acceptedEnglish

Job Description

• Utilizes clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant • Facilitates the overall quality, completeness and accuracy of medical record documentation through extensive record review • Knows, understands, incorporates and demonstrates the Trinity Mission, Vision and Values in behaviors, practices, standards policies procedures and decisions • Demonstrates understanding of appropriate clinical documentation to ensure the severity of illness, risk of mortality, quality indicators and level of services provided are accurately reflected in the health record • Communicates with and educates physicians and all other member of the healthcare team in clinical documentation and monitors provider engagement • Conducts concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency and precision of clinical documentation • Formulates compliant clarifications/queries following Trinity Health's documentation integrity procedures

Job Requirements

  • Must possess an Associate/Diploma Degree in Health Information Technology (HIT) or Advanced degree in nursing (NP, APN) or Physician Assistant
  • In absence of college degree, must have three (3) years' experience as an inpatient code or documentation specialist
  • Preferred Certifications: RN, RHIA, RHIT, CCS, CCDS or CDIP
  • Experienced in critical care, medical or surgical inpatient care nursing as an RN, PA, NP, APN or inpatient coder preferred
  • Excellent communication, interpersonal, collaboration and relationship building skills
  • Strong critical thinking skills, and ability integrate knowledge
  • Prioritization and organizations skills required
  • Demonstrated ability to use standardized desktop and Windows based computer system
  • Data entry and typing skills at minimum 30 wph

Benefits

  • Health insurance
  • Paid time off
  • Retirement plans

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