Clinical Documentation Specialist Audit Coordinator (Remote)

POSITION PURPOSE

Work Remote Position (Pay Range: $41.4306-$62.1459)
Provides onsite and remote clinical documentation integrity (CDI) support to the Health Ministry (HM) CDI programs as part of the System Office CDI Float Pool.
Utilizes advanced coding and/or clinical expertise to direct efforts toward the improvement and integrity of clinical documentation.
Reviews and/or audits medical record clinical documentation to support the medical necessity, severity of illness, risk of mortality, accurate coding, clinical evidence, resources consumed, and level of services rendered to all patients.

Essential Functions

• Demonstrates understanding of and facilitates appropriate clinical documentation, to ensure that the medical necessity, severity of illness, risk of mortality, accurate coding, clinical evidence, resources consumed, and level of services provided are accurately reflected in the health record.
• Conducts clinical documentation chart reviews and queries providers as appropriate to support RHMs staffing needs.
• Communicates with physicians and other members of the healthcare team at the HM regarding clinical documentation as part of local CDI Team assignment.
• Audits medical records, queries, CDS and coder assigned codes, CDI software entries, etc., as requested to provide feedback to the HMs for improvement opportunities.
• Trains end users in the use of CDI system software, standards, and workflow.
• Provides documentation education to providers and members of healthcare team at the RHM as part of CDI Team assignment or as requested.
• Assists the System Office Clinical Documentation Manager with all aspects of the CDI program across the system including data collection and maintenance of the CDI Dashboard.
• May develop educational content for providers and CDSs on CDI workflow and processes, CDI and Physician software systems, and documentation and coding guidelines as requested.
• Performs other duties as assigned by leadership.

Minimum Qualifications

• Current Registered Nurse License, Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS) Certification as a Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred.
• Experience in Clinical Documentation Integrity.
• Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills.
• Strong critical thinking skills and ability to integrate knowledge.
• Prioritization and organizational skills required.
• Ability to educate all members of the healthcare team related to clinical documentation.
• Experience With Databases, Spreadsheet Software And Presentation Software Preferred.
• Must be comfortable operating independently in a collaborative, shared leadership environment.
• Must possess the ability to comply with Trinity Health policies and procedures.

Physical And Mental Requirements And Working Conditions

• Must be able to set and organize own work priorities and adapt to them as they change frequently.
• Must be able to work concurrently on a variety of tasks/projects in an environment that may be stressful with individuals having diverse personalities and work styles.
• Must possess the ability to comply with Trinity Health policies and procedures.
• Must be able to spend majority of work time utilizing a computer, monitor, and keyboard.
• Must be able to perform some lifting and/or pushing/pulling up to 20 pounds.
• Must be able to work with interruptions and perform detailed tasks.
• Must be able to work on different projects simultaneously and coordinate work to meet deadlines.
• Requires the ability to concentrate and read for long periods of time.
• Involves a wide array of physical activities, primarily walking, standing, balancing, sitting, squatting, and reading.
• Must be able to sit for long periods of time.