[Hiring] Clinical Documentation Specialist @Trinity Health

Role 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. Facilitates the overall quality, completeness, accuracy and integrity of medical record documentation through extensive record review.

Through extensive interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients. Participates in the development and delivery of education for providers and members of the healthcare team.

• Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values.
• Demonstrates understanding of appropriate clinical documentation to ensure accurate reflection of severity of illness, risk of mortality, and level of services provided.
• Assists in overall quality, timeliness, and completeness of the health record.
• Serves as a resource for appropriate clinical documentation.
• Communicates with and educates physicians and healthcare team members regarding clinical documentation.
• Identifies learning opportunities for healthcare providers.
• Conducts concurrent reviews of selected patient health records for documentation quality.
• Formulates compliant clarifications/queries following Trinity Health’s documentation integrity procedures.
• Interacts with healthcare staff regarding documentation requirements and educational opportunities.
• Accurately codes relevant diagnoses codes and establishes working diagnoses and DRG.
• Collaborates with coding staff to ensure complete reflection of patient’s clinical status.
• Demonstrates expertise in problem-solving and serves as a professional role model.
• Proficient with leveraging the functions of 3M/360 for data entry related to CDI efficiencies.
• Maintains knowledge of applicable laws, regulations, and policies to ensure adherence.

Qualifications

• Must possess an Associate/Diploma Degree in Nursing, Health Information Technology (HIT), or an Advanced degree in nursing or medical field.
• Must possess one of the following:
  • Current Registered Nurse License in the State of practice
  • Registered Health Information Administrator (RHIA)
  • Registered Health Information Technician (RHIT)
  • Certified Coding Specialist (CCS) required
  • Licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APN) or completion of medical school
• 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, PA, NP/APN, medical school graduate, or as an inpatient coder preferred.
• Excellent communication (verbal and written), interpersonal, collaboration, and relationship-building skills.
• Strong critical thinking skills and ability to integrate knowledge.
• Prioritization and organizational skills required.
• Effective presentation/facilitation skills for educational goals.
• Demonstrated ability to use a standard desktop and Windows-based computer system.
• Experience with databases, spreadsheet software, and presentation software preferred.
• Accurate data entry skills and typing skills at minimum 30 wpm.
• Must be comfortable operating independently and in a collaborative environment.
• Must possess a personal presence characterized by honesty, integrity, and caring.

Requirements

• Must be comfortable operating independently and in a collaborative environment.
• Must possess a personal presence characterized by honesty, integrity, and caring.

Benefits

• Rooted in our Mission and Core Values, we honor the dignity of every person.
• Recognize the unique perspectives, experiences, and talents each colleague brings.
• Equal Opportunity Employer: All qualified applicants will receive consideration for employment without regard to protected status.