Clinical Documentation Specialist – CDI HIM

Role Overview

• Achieves appropriate clinical documentation to support the medical necessity and level of services rendered to all patients.
• 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 to ensure appropriate data and provider communication.
• Serves as a resource for appropriate clinical documentation.
• Communicates with and educates physicians and healthcare team members regarding clinical documentation and monitors provider engagement.
• Identifies learning opportunities for healthcare providers.
• 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.
• Interacts with physicians, nurses, and ancillary staff regarding compliant documentation requirements and educational opportunities.
• Accurately codes all relevant, appropriate, and compliant working diagnoses codes.

Requirements

• Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) OR Advanced degree in nursing or medical field such as NP/APN or PA.
• 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.
• Preferred: 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, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), medical school graduate or as an inpatient coder preferred.

Benefits

• Competitive compensation.
• Full benefits package including Medical, Dental, Vision, PTO, Life Insurance, Short and Long-term Disability.
• Benefits effective Day One! No waiting periods.
• Retirement savings plan with employer match.
• Opportunity for growth and advancement throughout Trinity Health.
• Tuition Reimbursement