Clinical Documentation Specialist Remote

Trinity Health; Davenport (IA); Remoto; USD 65.000 - 90.000; Tempo pieno

Descrizione del lavoro

Trinity Health's MercyOne Genesis remote position seeks a clinician with HIT or nursing background to lead documentation integrity. You will review and educate on medical records, and advise providers to ensure accurate severity of illness and quality indicators.

With inpatient coding experience and strong communication, you will support the care team across the health system, working remotely to improve documentation quality and patient safety while upholding Trinity Health's mission.

Competenze

• AA or higher in Health Information Technology (HIT) or Nursing degree, or 3 years inpatient coding/clinical documentation experience.
• RHIA/RHIT/CCS/CCDS/CDIP certifications are preferred.
• Experience in critical care, inpatient coding or documentation highly desirable.
• Excellent communication, collaboration and relationship-building skills.
• Data entry ability with at least 30 wpm typing speed.

Mansioni

• Direct the integrity of clinical documentation as reviewer, educator and consultant.
• Educate physicians and care team on documentation and engage providers.
• Conduct concurrent reviews to ensure legibility, completeness and accuracy of records.
• Formulate compliant clarifications/queries per documentation integrity procedures.
• Support quality, completeness and accuracy of medical record documentation.

Conoscenze

Communication

Interpersonal skills

Collaboration

Critical thinking

Data entry

Formazione

Associate/Diploma HIT

Nursing degree (NP/APN)

Physician Assistant degree

Strumenti

RHIA certification

RHIT certification

CCS certification

CCDS certification

CDIP certification

Descrizione del lavoro

Employment Type:Full timeShift:Day ShiftDescription:MercyOne Genesis Full-Time Remote Position (80 Hours Biweekly)

AA degree in Nursing or HIT. In absence of degree, 3 years' experience as an inpatient code or clinical documentation specialist.

Position Purpose:

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.