Remote CDI & Documentation Quality Specialist

Trinity Health; City of Syracuse (NY); On-site; USD 50,000 - 66,000; Full time

Job summary

Trinity Health is seeking a Clinical Documentation Specialist (Remote) to ensure documentation integrity and regulatory compliance across patient records. The role involves reviewing charts, collaborating with physicians and staff, and conducting audits to identify gaps and opportunities for improvement.

We offer a comprehensive 12-week onboarding and expect strong communication, detail orientation, and experience in inpatient coding or clinical documentation.

Qualifications

• Must hold an Associate/Diploma Degree in Nursing or Health Information Technology (HIT) or an Advanced degree in nursing or medical field (MD/DO/NP/APN/PA).
• 3+ years’ experience as an inpatient coder or clinical documentation specialist.
• Preferred certifications: RN license, RHIA, RHIT, CCS, CCDS, CDIP.

Responsibilities

• Review, audit, and analyze patient charts for documentation accuracy and completeness.
• Collaborate with physicians and clinical staff to improve documentation quality.
• Conduct chart audits to identify gaps and opportunities for improvement.
• Ensure documentation supports coding, medical necessity, severity of illness, and level of services.
• Provide education to providers and healthcare team on documentation requirements.
• Utilize 3M/360 tools for data entry related to CDI efficiencies.

Skills

Communication skills

Data entry 30 wpm

Independent work

Collaboration

Education

Associate/Diploma in Nursing

Health Information Technology

Advanced degree in nursing/medical field

Tools

3M/360

Job description

Trinity Health is seeking a Clinical Documentation Specialist (Remote) to ensure documentation integrity and regulatory compliance across patient records. The role involves reviewing charts, collaborating with physicians and staff, and conducting audits to identify gaps and opportunities for improvement.

We offer a comprehensive 12-week onboarding and expect strong communication, detail orientation, and experience in inpatient coding or clinical documentation.