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Form of workPlease check Minimum Requirements carefully
REQUIRES PREVIOUS EXPERIENCE IN DOCUMENTATION IMPROVEMENT (CDS/CDI) in addition to nursing or other healthcare roles.
Position Purpose
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. This position may be fully remote.
What you will do
Ensure that 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
Conduct concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency and precision of Clinical Documentation
Leverage the functions of 3M/360 for entering data
Collaborate with coding staff to ensure documentation of discharge diagnoses and co-morbidities are complete
Minimum Qualifications
Applicants for this position must be authorized to work for any employer in the U.S. We are unable to sponsor an employment visa for this position
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
Must possess one of the below:
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
Position Highlights and Benefits
Full time 40 hours Mon-Fri days
Great Benefits and Health Insurance Coverage—starting Day One!
Ministry/Facility Information
Trinity Health Of New England is an integrated health care delivery system comprised of world-class providers and facilities dedicated to the full spectrum of preventive, acute, and post-acute care, all delivered with the triple aim of better health, better care, and lower costs for our patient populations
Our Commitment to Diversity and Inclusion
Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.
