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In accordance with the Mission and Guiding Behaviors; 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.

Job Qualifications (Knowledge, Skills, and Abilities)

• Education: Associate/Diploma Degree in Nursing and minimum 5 years acute care medical or surgical experience required. Bachelor of Science in Nursing preferred. A degree in Health Information Management with credentials of RHIA, RHIT, or CCS with extensive clinical knowledge and a minimum of 5 years inpatient coding experience will be considered in lieu of a RN..
• Licensure / Certification: Current Registered Nurse License in the State of practice. Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), or Certified Coding Specialist (CCS) will be considered in lieu of a RN. Certified Clinical Documentation Specialist (CCDS) preferred.
• Experience: Minimum of 5 years acute care medical or surgical experience required; Utilization/Case Management, managed care, or Clinical Documentation with experience in ICD-10 coding conventions and DRG methodology preferred.

Our Commitment to Diversity and Inclusion
 

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.