Role Description The Clinical Documentation Specialist coordinates and maintains the elements and requirements of the Clinical Documentation Improvement Program, including staff and physician education, to ensure the highest quality of documentation in support of compliance and accurate representation of the care provided to the patient. - Coordinates and maintains all elements of the Clinical Documentation Improvement Program to meet the goals and objectives of the organization and its stakeholders. - Meets CDI program objectives, goals, and balance scorecard metrics. - Ensures timely, accurate, and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes. - Ensures effective communications with key stakeholders. - Analyzes data and creates reports to meet desired outcomes. - Identifies trends and opportunities for improvement in clinical documentation. - Meets program quality and productivity guidelines and standards. - Collaborates with coding professionals to fully support the needs of clinical code assignment and communicates proficiently with coding professionals to resolve identified discrepancies. - Works effectively with CDI team members to accomplish departmental goals. - Demonstrates continued advancement in professional growth. - Performs duties in compliance with Company’s policies and procedures, including but not limited to those related to HIPAA and compliance. Qualifications - Ability to prioritize and multi-task in a multifaceted environment. - Demonstrate strong organizational skills and be detail oriented. - Demonstrate ability to self-motivate, set goals, and meet deadlines. - Demonstrate mentoring and interpersonal skills. - Demonstrate excellent presentation, verbal, and written communication skills. - Ability to develop and maintain relationships with key business partners by building personal credibility and trust. - Maintains courteous and professional working relationships with employees at all levels of the organization. - Demonstrate successful leadership skills with the use of critical thinking, problem solving, and deductive reasoning required. - Specialized training in advanced computer skills with proficiency in Microsoft Word, Excel, PowerPoint, and Outlook e-mail required. - Additional training in Access database management, Medicare Part A and B programs, DRG assignment, and knowledge of MCC/CC preferred. Requirements - Experience: Bachelor’s degree in healthcare field (e.g., nursing, health information management) OR equivalent combination of education/experience combined required. (One year of education equals one year of experience). - Minimum Experience: Minimum of one to three years’ experience in clinical quality, utilization management, case management, nursing, coding, or a related field. - Preferred Experience: Three to five years’ experience in a Clinical Documentation Improvement Program with previous experience in clinical quality, utilization management, case management, nursing, coding, or related field (e.g., physician) of which a minimum of three years’ experience is in a management or supervisory role. - Education: Bachelor’s degree, with a healthcare related credential. Benefits - Comprehensive benefits package that may include health, dental, and vision coverage. - Voluntary insurance options. - 401(k) plan with employer match. - Professional development opportunities. - Paid time off and holiday pay. - Opportunity to participate in bonus programs, commissions, or other variable incentive plans.

• To write and edit complex medical writing deliverables (including informed consent forms, clinical study reports, clinical evaluation reports, CTD submissions) in accordance with sponsors’ and Excelya’s SOPs, guidelines and applicable legislation. • To coordinate cross-functional stakeholders and departments (including Clinical Operations, Biostatistics, Data Management, Regulatory Affairs, PV) to ensure the timely collection, review, alignment, and integration of scientific and clinical content required for the development of high-quality medical writing deliverables (including clinical study protocols, IBs, INDs). • To ensure the accuracy, consistency and regulatory compliance of all information, data and references included in the produced publications/documents, maintaining high standards of scientific quality. • To contribute to document quality control (reviewing data accuracy, formatting, appropriateness of language and compliance with industry guidelines). • To mentor and lead less experienced Medical Writers on complex projects, and to support the Principal Medical Writer with the coordination of other Medical Writers or Senior Medical Writers. • To liaise with sponsors to negotiate changes where necessary and ensure alignment on deliverables and expectations.

Title: Clinical Documentation Integrity Specialist Location: United States Job Description: Facility: Work from Home - Hybrid - Ohio Department: Clinical Documentation Schedule: Full time Hours: 40 Job Details: Ensures overall quality and completeness of clinical documentation on inpatient records. Facilitates clarification of clinical documentation through extensive concurrent interaction with physicians, nursing staff, other patient caregivers, and medical records coding staff to ensure that appropriate clinical severity is captured for the level of service rendered to all patients. Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes. Educates/trains all members of the patient care team on an ongoing basis. Department Specific Job Details: Education - Bachelors degree in Nursing required Certifications/Licenses - RN: Registered Nurse License required - CCDS (certified clinical documentation specialist) preferred Experience - 3+ years clinical experience as an RN required - Prior experience in clinical documentation preferred

Title: Clinical Documentation Specialist - Full Time - CDI HIM (Remote) Location: Pontiac, Michigan, United States Job Description: CategoryNursing Job Id00675975Trinity Health Michigan Employment Type: Full time Shift: Day Shift Description: 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). MINIUMUM QUALIFICATIONS - 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. 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. POSITION BENEFITS AND HIGHLIGHTS - 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 Our Commitment Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are 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, veteran status, or any other status protected by federal, state, or local law.