Clinical Documentation Specialist - (Remote)

About the Role

Trinity Health Oakland is seeking an experienced Clinical Documentation Specialist (CDS) with a strong clinical background to improve documentation integrity across inpatient care settings. This fully remote position offers flexible scheduling options and is a full-time, benefited role scheduled for 40 hours per week (1.0 FTE).

Qualifications

Preferred:

• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP)
• Two (2) years’ experience as an inpatient coder or experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN)

Required:

• Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) OR Advanced degree in nursing or medical field such as APP
• One of the following credentials:
  • Current Registered Nurse License in the State of practice
  • Registered Health Information Administrator (RHIA)
  • Registered Health Information Technician (RHIT)
  • Certified Coding Specialist (CCS)
  • Licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APN) or completion of medical school

Responsibilities

• Through extensive interaction with physicians, nursing staff, and other patient caregivers, ensure appropriate clinical documentation to support the medical necessity and level of services rendered to all patients
• Demonstrate understanding of appropriate clinical documentation to ensure the severity of illness, risk of mortality, and level of services provided are accurately reflected in the health record
• Assist in overall quality, timeliness, and completeness of the health record to ensure appropriate data, provider communication, and quality outcomes
• Serve as a resource for appropriate clinical documentation
• Communicate with and educate physicians and all other members of the healthcare team regarding clinical documentation and monitor provider engagement
• Identify learning opportunities for healthcare providers
• Conduct concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency, and precision of clinical documentation
• Formulate compliant clarifications/queries following Trinity Health’s documentation integrity procedures
• Interact with physicians, nurses, and ancillary staff regarding compliant documentation requirements, clarification/query requests, and educational opportunities
• Accurately code all relevant, appropriate, and compliant working diagnoses codes, establishing a working principal diagnosis and working DRG (MS or APR)
• Collaborate with coding staff to ensure documentation of discharge diagnoses and comorbidities are a complete reflection of the patient’s clinical status and care
• Resolve all discrepancies in a courteous manner

Benefits

• Full benefits package including Medical, Dental, Vision, PTO, Life Insurance, Short and Long-term Disability (effective Day One with no waiting periods)
• Retirement savings plan with employer match
• Opportunity for growth and advancement throughout Trinity Health
• Tuition Reimbursement