Clinical Documentation Specialist
Company: Trinity Health
Posted on: January 23, 2023
Full time Shift:
Description: Hourly pay range: $34.06 - $51.09
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.
Through extensive interaction with physicians and other members of
the healthcare team, achieves appropriate clinical documentation to
support code assignment, medical necessity, severity of illness,
risk of mortality and level of services rendered to all patients.
Participates in the development and delivery of education for
providers and members of the healthcare team.
Knows, understands, incorporates, and demonstrates the Trinity
Health Mission, Vision, and Values in behaviors, practices,
standards, policies, procedures and decisions.
Demonstrates understanding of 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.
Assists in overall quality, timeliness and completeness of the
health record to ensure appropriate data, provider communication
and quality outcomes. Serves as a resource for appropriate clinical
Communicates with and educates physicians and all other members of
the healthcare team regarding clinical documentation and monitors
provider engagement. Identifies learning opportunities for
Conducts concurrent reviews of selected patient health records to
address legibility, clarity, completeness, consistency and
precision of clinical documentation.
Formulates compliant clarifications/queries following Trinity
Health's documentation integrity procedures.
Interacts with physicians, nurses and ancillary staff regarding
compliant documentation requirements, clarification/query requests
and educational opportunities.
Codes all relevant, appropriate and compliant working diagnoses
codes, establishing a working principle diagnosis and working DRG
(MS or APR).
Collaborates with coding staff to ensure documentation of discharge
diagnoses and co-morbidities are a complete reflection of the
patient's clinical status and care. Resolves all discrepancies in a
Demonstrates expertise in problem-solving skills based on
theoretical knowledge, clinical experience and sound judgement and
serves as a professional role model by demonstrating desirable
Leverages the functions of 3M/360 for entering data related to CDI
efficiencies and effectiveness.
Performs other duties as assigned by leadership.
Maintains a working knowledge of applicable Federal, State and
local laws and regulations, accrediting agencies, Trinity Health's
Organizational Integrity Program, Standards of Conduct, Code of
Ethics, as well as other policies and procedures in order to ensure
adherence in a manner that reflects honest, ethical and
Must possess an Associate/Diploma Degree in Nursing, or Health
Information Technology (HIT) or related education and
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),
Certified Clinical Documentation Specialist (CCDS) or Certified
Documentation Improvement Professional (CDIP).
Two (2) years experience in Critical Care, Medical or Surgical
Inpatient Care Nursing, as an RN, related field, or as an inpatient
Excellent communication (verbal and written), interpersonal,
collaboration and relationship-building skills. Strong critical
thinking skills and ability to integrate knowledge. Prioritization
and organizational skills required. Effective
presentation/facilitation skills to accomplish educational goals
for all members of the healthcare team.
Demonstrated ability to use a standard desktop and Windows based
computer system, including a basic understanding of email, internet
and computer navigation. Ability to use other software as required
to perform the essential functions on the job. Experience with
databases, spreadsheet software and presentation software
Data entry skills and typing skills at minimum 30 wpm.
Must be comfortable operating independently and in a collaborative
Must possess a personal presence that is characterized by a sense
of honesty, integrity and caring with the ability to inspire and
motivate others to promote the philosophy, mission, vision, goals
and values of Trinity Health.
PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS
Must be able to set and organize own work priorities and adapt to
them as they change frequently. Must be able to work concurrently
on a variety of tasks/projects in an environment that may be
stressful with individuals having diverse personalities and work
Must possess the ability to comply with Trinity Health policies and
Must be able to spend majority of work time utilizing a computer,
monitor and keyboard.
Must be able to work with interruptions and perform detailed
Ability to concentrate and read for long periods of time.
Ability to work in an onsite and virtual environment.
Must possess a valid driver's license and be able to travel to the
various Trinity Health sites (10%) as needed.
The above statements are intended to describe the general nature
and level of work being performed by persons assigned to this
classification. They are not to be construed as an exhaustive list
of duties so assigned.
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
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.
Keywords: Trinity Health, Livonia , Clinical Documentation Specialist, Other , Livonia, Michigan
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