CLINICAL DOCUMENTATION SPECIALIST

Employment Type:

Full time

Shift:

Day Shift

Description:

Come join our Health Information Management team at Trinity Health Of New England!

This position may be fully remote. Please check qualifications carefully!!!

Position Purpose

The Clinical Documentation Specialist utilizes advanced 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, accuracy and integrity of medical record documentation through extensive record review.

What you will do

• Understand appropriate clinical documentation to ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record

• Communicate with physicians and all other members of the healthcare team regarding clinical documentation and monitor provider engagement; identify learning opportunities for healthcare providers

• Conduct concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency and precision of clinical documentation

• Leverage the functions of 3M/360 for entering data related to CDI efficiencies and effectiveness

• Maintain a working knowledge of applicable Federal, State and local laws and regulations, accrediting agencies

• Ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient's clinical status and care

Minimum Qualifications

Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) OR an Advanced degree in nursing or medical field such as NP/APN or PA.

Must possess one of the below

• Current Registered Nurse License in the State of practice,

• Registered Health Information Administrator (RHIA),

• Registered Health Information Technician (RHIT),

• Certified Coding Specialist (CCS) required,

• licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APN) or completion of medical school.

Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred.

Two (2) years experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), medical school graduate or as an inpatient coder preferred.

Applicants for this position must be authorized to work for any employer in the U.S. We are unable to sponsor an employment visa for this position.

Position Highlights and Benefits

• Full time salaried 40hrs M-F days

• Great benefits and Health Insurance Coverage

Ministry/Facility Information

Trinity Health Of New England is an integrated health care delivery system that is comprised of world-class providers and facilities dedicated to full spectrum preventative, acute, and post-acute care. We aim to deliver top level care to increase our community's overall health at lower costs. While we serve nearly 3 million people, we are proud to be a part of a national system that focuses on putting our patients first and having the best colleagues to do so

Our Commitment to Diversity and Inclusion

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is 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, status as a protected veteran, or any other status protected by law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran