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Clinical Documentation Specialist
Trinity Health. Demonstrate Trinity Mission, Vision and Values in behaviors, practices, standards, policies, procedures and decisions .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical documentation integrity, ensuring accurate representation of patient health records while adhering to compliance standards. Possesses strong communication and critical thinking skills to effectively engage with healthcare teams and enhance documentation practices.
Highest-signal resume keywords
Clinical Documentation IntegrityHealth 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 DocumentationInpatient CodingHealth Record ReviewDocumentation ComplianceData EntryTyping Skills
Soft Skills
Communication SkillsInterpersonal SkillsCollaboration SkillsCritical ThinkingOrganizational Skills
Tools & Technologies
Standardized Desktop SystemsWindows-Based Computer Systems
Certifications & Qualifications
RNRHIARHITCCSCCDSCDIP
Industry Keywords
Health Information TechnologyClinical DocumentationPatient Health RecordsInpatient CareQuality Indicators
About the role
Key responsibilities & impact- Demonstrate Trinity Mission, Vision and Values in behaviors, practices, standards, policies, procedures and decisions
- 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
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 a 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 organizational skills
- Ability to use standardized desktop and Windows-based computer systems
- Data entry and typing skills at minimum 30 wpm
Benefits
Comp & perks- Full-time employment
- Day shift
- Remote work position