Clinical Documentation Specialist

Trinity Health

. Utilize clinical and coding expertise to direct efforts toward the integrity of clinical documentation as reviewer, educator and consultant .

Posted 9/18/2026full-timeRemote • Iowa • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical documentation integrity, ensuring accurate representation of patient health records while educating healthcare professionals. Proficient in critical care and inpatient coding, with strong communication and organizational skills.

Highest-signal resume keywords

Clinical Documentation IntegrityInpatient CodingCritical Care ExperienceExcellent Communication SkillsData Entry Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Documentation ReviewMedical Record ReviewCoding ExpertiseDocumentation ComplianceHealth Information Technology

Soft Skills

Interpersonal SkillsCollaboration SkillsCritical Thinking SkillsPrioritization SkillsOrganizational Skills

Tools & Technologies

Standardized Desktop SystemsWindows Based Computer Systems

Certifications & Qualifications

RNRHIARHITCCSCCDSCDIP

Industry Keywords

HealthcareClinical DocumentationPatient Health RecordsQuality IndicatorsRisk of Mortality

About the role

Key responsibilities & impact

Utilize clinical and coding expertise to direct efforts toward the integrity of clinical documentation as reviewer, educator and consultant
Facilitate the quality, completeness and accuracy of medical record documentation through extensive record review
Ensure clinical documentation accurately reflects severity of illness, risk of mortality, quality indicators and level of services provided
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 following Trinity Health's documentation integrity procedures
Demonstrate the Trinity Mission, Vision and Values in 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 code 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 required
Demonstrated ability to use standardized desktop and Windows based computer system
Data entry and typing skills at minimum 30 wpm

Benefits

Comp & perks

Full-time remote position
Day shift
Equal Opportunity Employer