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Clinical Documentation Specialist
Trinity Health. Utilize clinical and coding expertise to support the integrity of clinical documentation as reviewer, educator and consultant .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical documentation integrity, including thorough record review and effective communication with healthcare professionals. Proficient in utilizing coding knowledge to ensure accurate medical record documentation and compliance with established standards.
Highest-signal resume keywords
Clinical Documentation ReviewHealth Information TechnologyRN, RHIA, RHIT, CCS, CCDS, CDIP CertificationsCritical Care ExperienceData Entry Skills
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Documentation IntegrityInpatient CodingRecord ReviewDocumentation ComplianceMedical Record Accuracy
Soft Skills
Excellent CommunicationInterpersonal SkillsCollaborationCritical ThinkingOrganizational Skills
Tools & Technologies
Standardized Desktop SystemsWindows-Based Computer Systems
Certifications & Qualifications
RNRHIARHITCCSCCDSCDIP
Industry Keywords
Clinical DocumentationHealthcare Team EducationPatient Health RecordsSeverity of IllnessRisk of Mortality
About the role
Key responsibilities & impact- Utilize clinical and coding expertise to support the integrity of clinical documentation as reviewer, educator and consultant
- Facilitate the quality, completeness and accuracy of medical record documentation through extensive record review
- Demonstrate understanding of documentation needed to accurately reflect severity of illness, risk of mortality, quality indicators and level of services
- Communicate with and educate physicians and healthcare team members on clinical documentation
- Monitor provider engagement
- Conduct concurrent reviews of selected patient health records for legibility, clarity, completeness, consistency and precision
- Formulate compliant clarifications/queries according to Trinity Health documentation integrity procedures
- Incorporate the Trinity Mission, Vision and Values into behaviors, practices, standards, policies, procedures and decisions
Requirements
What you’ll need- Associate/Diploma Degree in Health Information Technology (HIT) or advanced degree in nursing (NP, APN) or Physician Assistant
- In absence of college degree, three (3) years' experience as an inpatient coder or documentation specialist
- Preferred 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 preferred
- Excellent communication, interpersonal, collaboration and relationship building skills
- Strong critical thinking skills and ability to integrate knowledge
- Prioritization and organization skills
- Ability to use standardized desktop and Windows-based computer systems
- Data entry and typing skills of at least 30 wpm
Benefits
Comp & perks- Full-time remote position
- Day shift
- Equal Opportunity Employer