Clinical Documentation Specialist - Full Time - CDI HIM (Remote)

Description

POSITION PURPOSE
T Trinity Health Oakland is seeking an experienced Clinical Documentation Specialist (CDS) with a strong clinical background improving documentation integrity across inpatient care settings.

What You Will Do

• Through extensive interaction with physicians, nursing staff, and other patient caregivers, it achieves appropriate clinical documentation to support the medical necessity and level of services rendered to all patients.
• Demonstrates understanding of appropriate clinical documentation, to ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record.
• Aids in overall quality, timeliness and completeness of the health record to ensure appropriate data, provider communication and quality outcomes.
• Serves as a resource for appropriate clinical documentation.
• Communicates with and educates physicians and all other members of the healthcare team regarding 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.
• Communicates with physicians, nurses and ancillary staff regarding compliant documentation requirements, clarification/query requests and educational opportunities.
• Accurately codes all relevant, appropriate and compliant working diagnoses codes, establishing a working principal diagnosis and working DRG (MS or APR).
• Collaborates with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care.
• Resolves all discrepancies in a courteous manner.

Minimum Qualifications

• Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) OR Advanced degree in nursing or medical field such as NP/APN or PA.
• Must possess one of the following: Current Registered Nurse License in the State of practice, Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS) required.
• Licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APN) or completion of medical school.
• Preferred: Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred.
• Two (2) years’ experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), medical school graduate or as an inpatient coder preferred.