Remote Clinical Documentation Specialist | Elevate Records

Trinity Health Mid-Atlantic; Boise (ID); On-site; USD 85,000 - 110,000; Full time

Job summary

Saint Alphonsus Health System seeks a Clinical Documentation Specialist to review medical records and improve physician documentation, ensuring accurate representation of illness severity and mortality risk. The role involves extensive collaboration with physicians, HIM professionals, and nursing staff in a remote capacity.

Ideal candidates have RN license and BSN preferred or PA-C certification, with 3–5 years of hospital clinical experience and strong CC/M surgical background.

Qualifications

• Registered Nurse with RN license; BSN preferred or PA-C certification.
• Certification in RHIT/RHIA/CCDS/CDIP is a plus.
• 3–5 years hospital clinical experience required.
• Critical care or medical-surgical background preferred.
• Ability to pass a clinical competency exam.

Responsibilities

• Review medical records to ensure accurate representation of severity of illness and mortality risk.
• Input data into 3M 360 EnCOMPASS and Cerner PowerChart.
• Audit charts for accuracy and follow up on clarifications.
• Educate physicians, nursing, and ancillary staff on documentation improvement.
• Collaborate with HIM and coding staff to ensure complete discharge diagnoses and comorbidities.

Skills

RN license

BSN

PA-C

RHIT

RHIA

CCDS

CDIP

Clinical experience

Education

RN license (state)

BSN preferred

PA-C certification

RHIT

RHIA

CCDS

CDIP

Job description

Saint Alphonsus Health System seeks a Clinical Documentation Specialist to review medical records and improve physician documentation, ensuring accurate representation of illness severity and mortality risk. The role involves extensive collaboration with physicians, HIM professionals, and nursing staff in a remote capacity.

Ideal candidates have RN license and BSN preferred or PA-C certification, with 3–5 years of hospital clinical experience and strong CC/M surgical background.