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Clinical Documentation Specialist
Trinity HealthClinical Documentation Specialist enhancing clinical documentation integrity for Trinity Health. Collaborates with healthcare teams on quality and accuracy of medical records remotely.
About the role
Key responsibilities & impact- Utilizes advanced clinical and coding expertise for clinical documentation integrity
- Facilitates quality, completeness, and accuracy of medical record documentation
- Conducts concurrent reviews of selected patient health records
- Codes diagnoses and collaborates with coding staff for complete documentation
- Educates healthcare team members on clinical documentation standards
Requirements
What you’ll need- Associate/Diploma Degree in Nursing or Health Information Technology (HIT)
- 3 or more years’ experience as an inpatient coder or clinical documentation specialist
- Current Registered Nurse License, RHIA, RHIT, CCS, CCDS, CDIP preferred
- Experience in Critical Care, Medical or Surgical Inpatient Care Nursing
- Excellent communication and interpersonal skills
- Strong critical thinking and prioritization skills
- Effective presentation/facilitation skills
Benefits
Comp & perks- Health insurance
- Flexible work arrangements
- Professional development opportunities
- Paid time off
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical documentation integritycoding expertisemedical record documentationconcurrent reviewsdiagnosis coding
Soft Skills
communication skillsinterpersonal skillscritical thinkingprioritization skillspresentation skillsfacilitation skills
Certifications
Registered Nurse LicenseRHIARHITCCSCCDSCDIP