Clinical Documentation Specialist - (Remote)

Employment Type: Full time • Shift: Day Shift • Fully remote position with flexible scheduling options.

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. The Clinical Documentation Specialist utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator, and consultant. Facilitates the overall quality, completeness, accuracy, and integrity of medical record documentation through extensive record review.

Responsibilities

• Through extensive interaction with physicians, nursing staff, and other patient caregivers, achieve 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.

Requirements

• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred.
• Two (2) years’ experience as an inpatient coder preferred or experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN).
• Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) OR Advanced degree in nursing or medical field such as APP.
• 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.

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.