Clinical Documentation Specialist

Trinity Health

. Direct efforts toward the integrity of clinical documentation as a reviewer, educator and consultant .

Posted 10/2/2026full-timeRemote • Iowa • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical documentation integrity, ensuring accuracy and compliance in medical records while effectively communicating with healthcare professionals. Possesses strong critical-thinking and organizational skills to facilitate quality documentation practices.

Highest-signal resume keywords

Clinical Documentation ReviewInpatient Coding ExperienceRN, RHIA, RHIT, CCS, CCDS, CDIP CertificationsCritical Care Nursing ExperienceData Entry Skills

ATS Keywords

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Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Clinical Documentation IntegrityMedical Record ReviewDocumentation Requirements UnderstandingCompliant Clarifications/QueriesData EntryTyping Skills

Soft Skills

Excellent CommunicationInterpersonal SkillsCollaborationRelationship-BuildingCritical Thinking

Tools & Technologies

Standardized Desktop SystemsWindows-Based Computer Systems

Certifications & Qualifications

RNRHIARHITCCSCCDSCDIP

Industry Keywords

Clinical DocumentationHealthcare Team CommunicationQuality IndicatorsSeverity of IllnessRisk of Mortality

About the role

Key responsibilities & impact

Direct efforts toward the integrity of clinical documentation as a reviewer, educator and consultant
Facilitate the quality, completeness and accuracy of medical record documentation through extensive record review
Demonstrate understanding of documentation requirements so severity of illness, risk of mortality, quality indicators and level of services are accurately reflected
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
Incorporate Trinity Mission, Vision and Values into behaviors, practices, standards, policies, procedures and decisions

Requirements

What you’ll need

AA degree in Nursing or Health Information Technology (HIT), or advanced degree in nursing (NP, APN) or Physician Assistant
In absence of a college degree, three (3) years' experience as an inpatient coder or clinical 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
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
Equal Opportunity Employer
Consideration 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