Role Description To assist the hospital in achieving compliant, clear, complete, concise, concurrent documentation to support quality care and efficient and thorough post discharge coding for accurate classification and receipt of legitimate reimbursement optimization as well as to mitigate risk within the legal health record. Essential Duties and Responsibilities: - Provides concurrent review of clinical documentation in medical records. - Queries medical staff and other caregivers as necessary to obtain accurate and complete documentation that supports severity of patient illness and risk of mortality. - Performs a thorough chart review to identify co-morbidities/complications, and documents these appropriately within the concurrent DRG worksheet. - Demonstrates and understands the importance of and makes an effort to capture all appropriate secondary diagnoses for quality rating/proofing purposes. - Provides feedback to medical staff and conducts education. - Promotes a clean and safe environment of care, utilizing the SAFE error prevention habits. - Provides the highest standard of privacy and confidentiality in matters involving patients, coworkers, and the hospital by abiding by the Standards of Conduct. Qualifications - A minimum of a bachelor’s degree plus an RHIA®, RHIT®, CCS®, CCS-P®, RN, LVN, MD or DO and two (2) years of experience in clinical documentation improvement or inpatient coding OR - A minimum of a bachelor’s degree (or equivalent education) in an allied health field and three (3) years of experience in clinical documentation improvement or inpatient coding. The education component must include completed coursework in medical terminology and anatomy and physiology. - Excellent verbal, written, presentation, computer and interpersonal communication skills. - CCDS and/or CDIP Certification is ideal. - Highly Desired: ICD-10-CM/PCS Coding training and certification (may be provided on job). Requirements - Days, Remote - Department: CLINICAL DOCUMENTATION Benefits - Medical, Dental and Vision plans - Life Insurance - Flexible Spending Account - Other voluntary benefit plans - PTO and Sick time - 401(k) plan with a match - Wellness program - Tuition Reimbursement Registry employees who meet eligibility may participate in our 401(k) Savings plan with a potential match. However, registry employees are ineligible for Health and Welfare benefits. The final pay rate offered may be more than the posted range based on several factors including but not limited to: licensure, certifications, work experience, education, knowledge, demonstrated abilities, internal equity, market data, and more. The expected pay for this position is listed below: $38.98 - $49.70

Role Description 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. Through extensive interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients. Participates in the development and delivery of education for providers and members of the healthcare team. - Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values. - Demonstrates understanding of appropriate clinical documentation to ensure accurate reflection of severity of illness, risk of mortality, and level of services provided. - Assists in overall quality, timeliness, and completeness of the health record. - Serves as a resource for appropriate clinical documentation. - Communicates with and educates physicians and healthcare team members regarding clinical documentation. - Identifies learning opportunities for healthcare providers. - Conducts concurrent reviews of selected patient health records for documentation quality. - Formulates compliant clarifications/queries following Trinity Health’s documentation integrity procedures. - Interacts with healthcare staff regarding documentation requirements and educational opportunities. - Accurately codes relevant diagnoses codes and establishes working diagnoses and DRG. - Collaborates with coding staff to ensure complete reflection of patient’s clinical status. - Demonstrates expertise in problem-solving and serves as a professional role model. - Proficient with leveraging the functions of 3M/360 for data entry related to CDI efficiencies. - Maintains knowledge of applicable laws, regulations, and policies to ensure adherence. Qualifications - Must possess an Associate/Diploma Degree in Nursing, Health Information Technology (HIT), or an Advanced degree in nursing or medical field. - 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 - 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, PA, NP/APN, medical school graduate, or as an inpatient coder preferred. - Excellent communication (verbal and written), interpersonal, collaboration, and relationship-building skills. - Strong critical thinking skills and ability to integrate knowledge. - Prioritization and organizational skills required. - Effective presentation/facilitation skills for educational goals. - Demonstrated ability to use a standard desktop and Windows-based computer system. - Experience with databases, spreadsheet software, and presentation software preferred. - Accurate data entry skills and typing skills at minimum 30 wpm. - Must be comfortable operating independently and in a collaborative environment. - Must possess a personal presence characterized by honesty, integrity, and caring. Requirements - Must be comfortable operating independently and in a collaborative environment. - Must possess a personal presence characterized by honesty, integrity, and caring. Benefits - Rooted in our Mission and Core Values, we honor the dignity of every person. - Recognize the unique perspectives, experiences, and talents each colleague brings. - Equal Opportunity Employer: All qualified applicants will receive consideration for employment without regard to protected status.

• Research, write, and revise, high-quality, original editorial content across a range of project types (i.e. manuscripts, posters, abstracts, slide decks) • Assess projects to proactively identify areas that will require team collaboration (i.e. creative design, editorial support) and elicit help as needed • Liaise with clients, authors, speakers, and colleagues with professionalism and confidence • Orchestrate multiple activities at once to accomplish a goal; juggle multiple project types and deadlines by using time efficiently • Work with internal account teams to ensure projects are always delivered on time and on budget

• Develop, scientific integrity, and accuracy of medical content for pharmaceutical and medical device clients. • Serve as the lead medical writer for assigned clients, brands, or therapeutic areas. • Participate in client interactions and collaborate with cross-functional teams to execute deliverables efficiently and to quality expectations. • Support project pitch development and delivery by providing medical and scientific expertise to client engagement teams. • Provide medical and scientific support during client meetings, workshops, and advisory board meetings. • Prepare and submit content for medical legal regulatory review in client submission/referencing systems. • Collaborate with Design to ensure visuals are scientifically accurate and align with client preference/style guide and regulatory guidelines. • Conduct end-to-end validation of the content of projects, reporting and resolving issues with relevant team members.