Clinical Documentation Specialist Remote

About This Role

This remote position involves utilizing clinical and coding expertise to ensure the integrity of clinical documentation. The specialist will review medical records, educate healthcare teams, and act as a consultant to facilitate overall quality, completeness, and accuracy of documentation.

Responsibilities

• Know, understand, incorporate, and demonstrate the Trinity Mission, Vision, and Values in behaviors, practices, standards, policies, procedures, and decisions
• Demonstrate 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
• Communicate with and educate physicians and all other members of the healthcare team in clinical documentation and monitor provider engagement
• 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

Requirements

• 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
• Excellent communication, interpersonal, collaboration, and relationship building skills
• Strong critical thinking skills and ability to integrate knowledge
• Prioritization and organization skills required
• Demonstrated ability to use standardized desktop and Windows-based computer system
• Data entry and typing skills at minimum 30 wph

Nice to have:

• Certifications: RN, RHIA, RHIT, CCS, CCDS or CDIP
• Experience in critical care, medical or surgical inpatient care nursing as an RN, PA, NP, APN or inpatient coder

Important Details

• Shift: Day Shift

About the Company

MercyOne Genesis is committed to honoring the dignity of every person and recognizing the unique perspectives, experiences, and talents each colleague brings.