Employment Type:

Shift:

Description:

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. Facilitates the overall quality, completeness, accuracy and integrity of medical record documentation through extensive record review.

What you will do

• Understand 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

• Communicate with physicians and all other members of the healthcare team regarding clinical documentation and monitor provider engagement; identify learning opportunities for healthcare providers

• 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 related to CDI efficiencies and effectiveness

• Maintain a working knowledge of applicable Federal, State and local laws and regulations, accrediting agencies

• Ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care

Minimum Qualifications

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)

• Licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APRN) or completion of medical school

Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred.

CCS/CDS/CDI experience required, must be clear on resume

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. 

Position Highlights and Benefits

• Full time salaried 40hrs M-F days

• Great benefits and Health Insurance Coverage

Ministry/Facility Information

Trinity Health Of New England is an integrated health care delivery system that is comprised of world-class providers and facilities dedicated to full spectrum preventative, acute, and post-acute care. We aim to deliver top level care to increase our community's overall health at lower costs. While we serve nearly 3 million people, we are proud to be a part of a national system that focuses on putting our patients first and having the best colleagues to do so

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.