Clinical Documentation Specialist - REMOTE

Employment Type: Full time Shift: Day Shift Description: Come join our Health Information Management team at Saint Francis Hospital, a member of Trinity Health Of New England! REQUIRES PREVIOUS EXPERIENCE IN DOCUMENTATION IMPROVEMENT (CDS/CDI) in addition to general nursing or other healthcare roles. 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. This position may be fully remote. What you will do Ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record Assist in overall quality, timeliness and completeness of the health record to ensure appropriate data, provider communication and quality outcomes 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 Collaborate with coding staff to ensure documentation of discharge diagnoses and co-morbidities are complete Minimum Qualifications 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 Must possess one of the below: 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/APN) or completion of medical school Position Highlights and Benefits Full time 40 hours Mon-Fri days Great Benefits and Health Insurance Coverage—starting Day One! Ministry/Facility Information Trinity Health Of New England is an integrated health care delivery system comprised of world-class providers and facilities dedicated to the full spectrum of preventive, acute, and post-acute care, all delivered with the triple aim of better health, better care, and lower costs for our patient populations Our Commitment to Diversity and Inclusion Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is 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, status as a protected veteran, or any other status protected by law. Trinity Health is one of the largest not-for-profit, faith-based health care systems in the nation. Together, we’re 121,000 colleagues and nearly 36,500 physicians and clinicians caring for diverse communities across 27 states. Nationally recognized for care and experience, our system includes 101 hospitals, 126 continuing care locations, the second largest PACE program in the country, 136 urgent care locations, and many other health and well-being services. Based in Livonia, Michigan, in fiscal year 2023, we invested $1.5 billion in our communities through charity care and other community benefit programs. For more information, visit http://www.trinity-health.org. You can also follow Trinity Health on LinkedIn.

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