AA degree in Nursing or HIT. In absence of degree, 3 years' experience as an inpatient code or clinical documentation specialist
Position Purpose:
Utilizes 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 and accuracy of medical record documentation through extensive record review.
Essential Functions:
- Knows, understands, incorporates and demonstrates the Trinity Mission, Vision and Values in behaviors, practices, standards policies procedures and decisions.
- Demonstrates understanding of appropriate clinical documentation to ensure the severity of illness, risk of mortality, quality indicators and level of services provided are accurately reflected in the health record.
- Communicates with and educates physicians and all other member of the healthcare team in clinical documentation and monitors provider engagement.
- 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.
Minimum Qualifications:
- Must possess an Associate/Diploma Degree in Health Information Technology (HIT) or Advanced degree in nursing (NP, APN) or Physician Assistant. In absence of college degree, must have three (3) years' experience as an inpatient code or documentation specialist.
- Preferred Certifications: RN, RHIA, RHIT, CCS, CCDS or CDIP
- Experienced in critical care, medical or surgical inpatient care nursing as an RN, PA, NP, APN or inpatient coder preferred
- Excellent communication, interpersonal, collaboration and relationship building skills. Strong critical thinking skills, and ability integrate knowledge. Prioritization and organizations skills required.
- Demonstrated ability to use standardized desktop and Windows based computer system. Data entry and typing skills at minimum 30 wph.
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.
Skills Required
- Associate or diploma degree in Health Information Technology, or an advanced nursing degree, or Physician Assistant qualification
- Three years of inpatient coding or clinical documentation specialist experience if no college degree is held
- RN, RHIA, RHIT, CCS, CCDS, or CDIP certification
- Experience in critical care or medical/surgical inpatient nursing, inpatient coding, or clinical documentation
- Strong communication, interpersonal, collaboration, relationship-building, critical-thinking, prioritization, and organizational skills
- Ability to use standardized desktop and Windows-based computer systems
- Data entry and typing speed of at least 30 words per minute
What We Do
Trinity Health is one of the largest not-for-profit, Catholic health care systems in the nation. It is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians caring for diverse communities across 25 states. Nationally recognized for care and experience, the Trinity Health system includes 88 hospitals, 131 continuing care locations, the second largest PACE program in the country, 125 urgent care locations and many other health and well-being services. Based in Livonia, Michigan, its annual operating revenue is $20.2 billion with $1.2 billion returned to its communities in the form of charity care and other community benefit programs.
