Utilizes 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 and accuracy of medical record documentation through extensive record review
Knows, understands, incorporates and demonstrates the Trinity Mission, Vision and Values in behaviors, practices, standards policies procedures and decisions
Demonstrates understanding of appropriate clinical documentation to ensure the severity of illness, risk of mortality, quality indicators and level of services provided are accurately reflected in the health record
Communicates with and educates physicians and all other members of the healthcare team in clinical documentation and monitors provider engagement
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

Associate/Diploma Degree in Health Information Technology (HIT) or Advanced degree in nursing (NP, APN) or Physician Assistant
3 years' experience as an inpatient code or documentation specialist (in absence of college degree)
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
Ability to integrate knowledge
Prioritization and organizational skills required
Demonstrated ability to use standardized desktop and Windows based computer system
Data entry and typing skills at minimum 30 wph

Clinical Documentation Specialist

Key skills