Clinical Documentation Specialist

Trinity Health

Clinical Documentation Specialist ensuring integrity and accuracy of clinical documentation. Engaging with healthcare teams and conducting health record reviews at Trinity Health.

Posted 6/17/2026full-timeRemote • Iowa • 🇺🇸 United StatesMid-LevelSeniorWebsite

About the role

Key responsibilities & impact

Utilizes 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 and accuracy of medical record documentation through extensive record review.
Knows, understands, incorporates and demonstrates the Trinity Mission, Vision and Values in behaviors, practices, standards policies procedures and decisions.
Demonstrates 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.
Communicates with and educates physicians and all other members of the healthcare team in clinical documentation and monitors provider engagement.
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.

Requirements

What you’ll need

Must possess an 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.
Preferred Certifications: RN, RHIA, RHIT, CCS, CCDS or CDIP
Experienced in critical care, medical or surgical inpatient care nursing as an RN, PA, NP, APN or inpatient coder preferred
Excellent communication, interpersonal, collaboration and relationship building skills.
Strong critical thinking skills, and ability integrate knowledge.
Prioritization and organizations skills required.
Demonstrated ability to use standardized desktop and Windows based computer system.
Data entry and typing skills at minimum 30 wph.

Benefits

Comp & perks

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.

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

clinical documentationcoding expertiserecord reviewdocumentation integritydata entrytyping skills

Soft Skills

communicationinterpersonal skillscollaborationrelationship buildingcritical thinkingprioritizationorganizational skills

Certifications

RNRHIARHITCCSCCDSCDIP