Full time
Day ShiftThis position may be fully remote.
Please check qualifications carefully!!! Multiple choices for licensure/certification however CCS/CDS/CDI experience is required
Position Purpose
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.
What you will do
Understand appropriate clinical documentation to ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record
Communicate with physicians and all other members of the healthcare team regarding clinical documentation and monitor provider engagement; identify learning opportunities for healthcare providers
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 related to CDI efficiencies and effectiveness
Maintain a working knowledge of applicable Federal, State and local laws and regulations, accrediting agencies
Ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care
Minimum Qualifications
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)
Licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APRN) or completion of medical school
Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred.
CCS/CDS/CDI experience required, must be clear on resume
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.
Position Highlights and Benefits
Full time salaried 40hrs M-F days
Great benefits and Health Insurance Coverage
Ministry/Facility Information
Trinity Health Of New England is an integrated health care delivery system that is comprised of world-class providers and facilities dedicated to full spectrum preventative, acute, and post-acute care. We aim to deliver top level care to increase our community's overall health at lower costs. While we serve nearly 3 million people, we are proud to be a part of a national system that focuses on putting our patients first and having the best colleagues to do so
Our Commitment
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.
Trinity Health is one of the largest not-for-profit, Catholic health care systems in the nation. It is a family of 123,000 colleagues and nearly 27,000 physicians and clinicians caring for diverse communities across 26 states. Nationally recognized for care and experience, the Trinity Health system includes 88 hospitals, 135 continuing care locations, the second largest PACE program in the country, 136 urgent care locations and many other health and well-being services. Based in Livonia, Michigan, its annual operating revenue is $21.5 billion with $1.4 billion returned to its communities in the form of charity care and other community benefit programs.
