Clinical Documentation Specialist Remote

IHA; Davenport (IA); On-site; USD 55,000 - 75,000; Full time

Job summary

Trinity Health in Davenport, IA seeks a Health Information Technician to apply clinical and coding expertise as reviewer, educator and consultant, ensuring the integrity, quality and accuracy of medical record documentation through extensive record review.

The role emphasizes communicating with physicians, conducting concurrent chart reviews, and issuing compliant clarifications and queries to support accurate severity of illness and service level reporting.

Qualifications

• Must possess an Associate/Diploma Degree in HIT or an advanced nursing/PA degree; if no degree, three years inpatient code or documentation experience required.
• Preferred certifications: RN, RHIA, RHIT, CCS, CCDS or CDIP.
• Experience in critical care or medical/surgical inpatient care preferred.
• Excellent communication, interpersonal, collaboration and relationship-building skills; strong critical thinking.
• Proficient with standardized desktop and Windows-based systems; data entry speed minimum 30 wpm.

Responsibilities

• Know and demonstrate Trinity Mission, Vision and Values in behaviors and decisions.
• Ensure documentation reflects severity of illness, risk of mortality, quality indicators and level of services.
• Communicate with physicians and care team about documentation and monitor engagement.
• Conduct concurrent reviews of patient records for legibility, clarity, completeness and accuracy.
• Formulate compliant clarifications/queries per documentation integrity procedures.

Skills

Communication skills

Interpersonal skills

Collaboration

Relationship building

Critical thinking

Education

Associate/Diploma in Health Information Technology

Advanced nursing degree (NP/APN)

Physician Assistant degree

Tools

Windows OS

Data entry 30 wpm

Job description

Description:

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.

Employment Type

Full time

Description:

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.

Essential Functions

• 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 member 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.

Minimum Qualifications

• Must possess an Associate/Diploma Degree in Health Information Technology (HIT) or Advanced degree in nursing (NP, APN) or Physician Assistant. In absence of college degree, must have three (3) years' experience as an inpatient code or documentation specialist.
• Preferred Certifications: RN, RHIA, RHIT, CCS, CCDS or CDIP
• Experienced 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 integrate knowledge. Prioritization and organizations skills required.
• Demonstrated ability to use standardized desktop and Windows based computer system. Data entry and typing skills at minimum 30 wph.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are 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, veteran status, or any other status protected by federal, state, or local law.