Clinical Documentation Specialist Remote

Trinity Health; United States; Remote; USD 60,000 - 90,000; Full time

Job summary

Trinity Health seeks a Remote Clinical Documentation Specialist for MercyOne Genesis on a full-time basis. The role supports inpatient coding and the accuracy of severity of illness, risk of mortality, and quality indicators in the health record.

An AA degree in Health Information Technology or an advanced nursing degree is required, or at least three years of inpatient coder or documentation experience. Excellent communication and collaboration with the healthcare team are essential for success.

Qualifications

• Associate or diploma in HIT or advanced nursing degree; or 3 years inpatient coder experience.
• Preferred certifications: RN, RHIA, RHIT, CCS, CCDS or CDIP.
• Experience in critical care or inpatient nursing preferred.
• Strong communication, collaboration and organizational skills.

Responsibilities

• Demonstrates Trinity Mission, Vision and Values in daily work.
• Communicates with physicians and healthcare team about clinical documentation.
• Monitors provider engagement in documentation.
• Conducts concurrent reviews to ensure legibility, clarity and accuracy.
• Formulates clarifications/queries per documentation integrity procedures.

Skills

Communication

Critical thinking

Data entry

Organization

Education

Associate/Diploma in HIT

Nursing degree (NP/APN) or PA

Tools

Windows OS

Job description

Employment Type:

Full time

Shift:

Day Shift

Description:

MercyOne Genesis Full-Time Remote Position (80 Hours Biweekly)
AA degree in Nursing or HIT. In absence of a degree, 3 years’ experience as an inpatient coder or a clinical documentation specialist required

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.