Trinity Health logo
Trinity Health

We are one of the largest not-for-profit, faith-based health care systems in the nation.

Clinical Documentation Specialist – CDI HIM

Location

Michigan

Posted

5 days ago

Salary

0

Seniority

Mid Level

Associate Degree2 yrs expEnglish

Job Description

Clinical Documentation Specialist – CDI HIM

Trinity Health

• 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 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 to ensure appropriate data and provider communication. • Serves as a resource for appropriate clinical documentation. • Communicates with and educates physicians and healthcare team members 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 and educational opportunities. • Accurately codes all relevant, appropriate, and compliant working diagnoses codes.

Job Requirements

  • Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) OR Advanced degree in nursing or medical field such as NP/APN or PA.
  • 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.
  • Preferred: 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.

Benefits

  • Competitive compensation.
  • Full benefits package including Medical, Dental, Vision, PTO, Life Insurance, Short and Long-term Disability.
  • Benefits effective Day One! No waiting periods.
  • Retirement savings plan with employer match.
  • Opportunity for growth and advancement throughout Trinity Health.
  • Tuition Reimbursement

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