About This Role
This role involves using advanced clinical and coding expertise to ensure the integrity of clinical documentation. The Clinical Documentation Specialist reviews, educates, and consults to facilitate the overall quality, completeness, accuracy, and integrity of medical record documentation through extensive record review.
Responsibilities
- Utilize advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation
- Facilitate the overall quality, completeness, accuracy, and integrity of medical record documentation through extensive record review
- Interact extensively with physicians and other members of the healthcare team to achieve appropriate clinical documentation
- Support code assignment, medical necessity, severity of illness, risk of mortality, and level of services rendered to all patients
- Participate in the development and delivery of education for providers and members of the healthcare team
- Demonstrate understanding of appropriate clinical documentation to ensure accurate reflection of severity of illness, risk of mortality, quality indicators, and level of services provided
- Assist in overall quality, timeliness, and completeness of the health record to ensure appropriate data, provider communication, and quality outcomes
- Serve as a resource for appropriate clinical documentation
- Communicate with and educate physicians and all other members of the healthcare team regarding clinical documentation
- Monitor provider engagement and 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
- Formulate compliant clarifications/queries following Trinity Health’s documentation integrity procedures
- Interact with physicians, nurses, and ancillary staff regarding compliant documentation requirements, clarification/query requests, and educational opportunities
- Code all relevant, appropriate, and compliant working diagnoses codes, establishing a working principle diagnosis and working DRG (MS or APR)
- Collaborate with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care
- Resolve all discrepancies in a courteous manner
- Demonstrate expertise in problem-solving skills based on theoretical knowledge, clinical experience, and sound judgement
- Serve as a professional role model by demonstrating desirable practice behaviors
- Leverage the functions of 3M/360 for entering data related to CDI efficiencies and effectiveness
- Perform other duties as assigned by leadership
- Maintain a working knowledge of applicable Federal, State, and local laws and regulations, accrediting agencies, Trinity Health’s Organizational Integrity Program, Standards of Conduct, Code of Ethics, as well as other policies and procedures to ensure adherence in an honest, ethical, and professional manner
Requirements
- Associate/Diploma Degree in Nursing, Health Information Technology (HIT), or an Advanced degree in nursing or medical field such as MD, DO, NP/APN or PA
- In the absence of a college degree, 3 or more years’ experience as an inpatient coder or clinical documentation specialist
- Excellent communication (verbal and written), interpersonal, collaboration, and relationship-building skills
- Strong critical thinking skills and ability to integrate knowledge
- Prioritization and organizational skills
- Effective presentation/facilitation skills to accomplish educational goals for all members of the healthcare team
- Demonstrated ability to use a standard desktop and Windows based computer system, including a basic understanding of email, internet, and computer navigation
- Ability to use other software as required to perform the essential functions on the job
- Data entry skills and typing skills at minimum 30 wpm
- Comfortable operating independently and in a collaborative environment
- Personal presence characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Trinity Health
- Ability to set and organize own work priorities and adapt to them as they change frequently
- Ability to work concurrently on a variety of tasks/projects in an environment that may be stressful with individuals having diverse personalities and work styles
- Ability to comply with Trinity Health policies and procedures
- Ability to spend majority of work time utilizing a computer, monitor, and keyboard
- Ability to work with interruptions and perform detailed tasks
- Ability to concentrate and read for long periods of time
Nice to have:
- Current Registered Nurse License
- Registered Health Information Administrator (RHIA)
- Registered Health Information Technician (RHIT)
- Certified Coding Specialist (CCS)
- Certified Clinical Documentation Specialist (CCDS)
- Certified Documentation Improvement Professional (CDIP)
- 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
- Experience with databases, spreadsheet software, and presentation software
Important Details
- Travel: 10% to various Trinity Health sites
- Work environment: onsite and virtual
About the Company
Trinity Health is committed to honoring the dignity of every person and recognizing the unique perspectives, experiences, and talents each colleague brings. They are an Equal Opportunity Employer and all qualified applicants receive consideration for employment without regard to protected status.
