Clinical Documentation Specialist

Employment Type: Full time

Shift: Day Shift

Position Purpose

• Trinity Health Oakland is seeking an experienced Clinical Documentation Specialist (CDS) with a strong clinical background improving 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.
• Fully remote position with flexible scheduling options.
• Full-Time benefited position. Scheduled 40 hours per week (1.0 FTE).

Minimum Qualifications

• Preferred:
• 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.

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. Assists 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. Identifies learning opportunities for healthcare providers.
• 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.
• Interacts 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.