Provides onsite and remote clinical documentation integrity (CDI) support to Health Ministry CDI programs as part of the System Office CDI Float Pool. The role uses advanced coding and clinical expertise to improve the accuracy and integrity of clinical documentation.
Responsibilities include reviewing and auditing medical record documentation to support medical necessity, severity of illness, risk of mortality, accurate coding, clinical evidence, resources consumed, and level of services rendered. The position audits CDS query compliance, workflow, and missed documentation opportunities, and trains end users on CDI software, standards, and workflow.
The role also supports documentation education for providers and healthcare team members, assists with CDI dashboard data collection and maintenance, and may develop educational content related to CDI workflow, software systems, and documentation and coding guidelines.
This position is part of Trinity Health's commitment to ethical, mission-driven care and compliance with applicable laws, regulations, and organizational policies.
Must possess at least one of the following:
- Current Registered Nurse license
- Registered Health Information Administrator (RHIA)
- Registered Health Information Technician (RHIT)
- Certified Coding Specialist (CCS)
Preferred:
- Clinical Documentation Specialist (CCDS)
- Certified Documentation Improvement Professional (CDIP)
Additional qualifications:
- Experience in Clinical Documentation Integrity
- Strong verbal and written communication skills
- Strong interpersonal, collaboration, and relationship-building skills
- Strong critical thinking and problem-solving ability
- Ability to educate healthcare team members on clinical documentation
- Prioritization and organizational skills
- Experience with databases, spreadsheet software, and presentation software preferred
- Ability to work independently in a collaborative environment
Location
Michigan, US
Employment Type
Full-time
Experience Level
Senior
Remote work allowed
Yes
Posted
1 month ago