Clinical Documentation Specialist Remote

About the role

Full‑time day‑shift remote position with MercyOne Genesis, 80 hours biweekly.

Responsibilities

• Knows, understands, incorporates and demonstrates the Trinity Mission, Vision and Values in behaviors, practices, standards, policies, procedures and decisions.
• Demonstrates understanding of appropriate clinical documentation to ensure the severity of illness, risk of mortality, quality indicators and level of services provided are accurately reflected in the health record.
• Communicates with and educates physicians and all other members of the healthcare team in 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.
• Formulates compliant clarifications/queries following Trinity Health's documentation integrity procedures.

Requirements

• Associate/Diploma Degree in Health Information Technology (HIT) or an Advanced degree in nursing (NP, APN) or Physician Assistant.
• In the absence of a college degree, three (3) years’ experience as an inpatient coder or documentation specialist.

Qualifications

• Preferred certifications: RN, RHIA, RHIT, CCS, CCDS, or CDIP.
• Experience in critical care, medical, or surgical inpatient care nursing as an RN, PA, NP, APN, or inpatient coder preferred.

Skills

• Excellent communication, interpersonal, collaboration, and relationship‑building skills.
• Strong critical thinking skills and ability to integrate knowledge.
• Prioritization and organizational skills.
• Demonstrated ability to use standardized desktop and Windows‑based computer systems.
• Data entry and typing skills of at least 30 wpm.

Schedule

Day‑shift, full‑time schedule (80 hours biweekly).