Clinical Documentation Specialist
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About The Position
The Clinical Documentation Specialist plays a crucial role in ensuring the integrity of clinical documentation within the healthcare system. This position is 100% remote and requires advanced clinical and coding expertise to facilitate the quality, completeness, accuracy, and integrity of medical record documentation. The specialist will engage extensively with physicians and other healthcare team members to ensure that clinical documentation accurately reflects the severity of illness, risk of mortality, and the level of services rendered to patients. This role involves conducting thorough reviews of patient health records, providing education to healthcare providers, and formulating compliant queries to enhance documentation practices. In addition to reviewing records, the Clinical Documentation Specialist will be responsible for coding relevant diagnoses and collaborating with coding staff to ensure that discharge diagnoses and co-morbidities are accurately documented. The specialist will also serve as a resource for clinical documentation best practices, identifying learning opportunities for healthcare providers, and monitoring their engagement in documentation processes. The position requires a strong understanding of applicable laws and regulations, as well as adherence to Trinity Health's Organizational Integrity Program and Standards of Conduct. The role is essential in promoting high-quality patient care through effective documentation practices, and the specialist will be expected to demonstrate problem-solving skills, sound judgment, and professional behavior in all interactions. The position also involves leveraging technology, such as 3M/360, to track documentation efficiency and effectiveness, and performing other duties as assigned by leadership.
