Employment Type:

Shift:

Description:

Utilizes advanced coding and/or clinical expertise to direct efforts toward the improvement of clinical documentation through the roles of educator and consultant. Facilitates improvement in the overall quality, completeness, and accuracy 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 the medical necessity and level of services rendered to all patients. Participates in the development and delivery of education for providers and members of the healthcare team.

What the Clinical Documentation Specialist II will do:

• Demonstrates understanding of and facilitates 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 quality 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 participation. Identifies learning opportunities for healthcare providers.
• Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, and decisions.
• Conducts concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency, and precision of clinical documentation.

What the Clinical Documentation Specialist II will need:

• Must possess a comprehensive knowledge of acute care nursing experience, as normally obtained through a Bachelor of Science, Nursing (BSN) and five (5) years on a medical or surgical unit, or Bachelor of Science in Health Information Management (HIM) and five (5) years HIM/inpatient coding experience, or an Associate/Diploma Degree in Nursing and ten (10) years on a medical or surgical unit, or an Associate Degree in Health Information Technology or in a related healthcare field. Ten (10) years' experience in acute inpatient coding preferred
• Experience in Critical Care, Utilization Management/Case Management, Clinical Documentation, ICD-9 Coding Guidelines and DRG assignment or patient outcomes/quality management, preferred.
• Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills. Strong critical thinking skills and ability to integrate knowledge. Prioritization and organizational skills required. Effective presentation/facilitation skills to accomplish educational goals for all members of the healthcare team.
• Current Registered Nurse License in the State of practice, Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), or Certified Coding Specialist (CCS). Certified Clinical Documentation Specialist (CCDS) 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.