The Clinical Documentation Specialist supports the integrity, completeness, accuracy, and quality of medical record documentation through review, education, and consultation.
This role works closely with physicians and other members of the healthcare team to improve clinical documentation that supports code assignment, medical necessity, severity of illness, risk of mortality, and level of services rendered. The position includes concurrent record review, provider education, compliant query/clarification development, and collaboration with coding staff to ensure discharge diagnoses and comorbidities accurately reflect the patient's clinical status.
The role also uses 3M/360 for CDI-related data entry and reporting, and contributes to organizational compliance with federal, state, and local regulations as well as Trinity Health standards and policies.
Qualifications
- Associate or diploma degree in Nursing or Health Information Technology, or an advanced nursing/medical degree such as NP/APN or PA
- Current Registered Nurse license, RHIA, RHIT, CCS, PA licensure, NP/APN licensure, or completion of medical school
- CCDS or CDIP preferred
- 2 years of experience in critical care, medical or surgical inpatient nursing, as an RN, PA, NP/APN, medical school graduate, or inpatient coder preferred
- Strong verbal and written communication skills
- Excellent interpersonal, collaboration, and relationship-building abilities
- Strong critical thinking, prioritization, and organizational skills
- Presentation and facilitation skills for provider education
- Proficiency with desktop and Windows-based computer systems
- Experience with databases, spreadsheets, and presentation software preferred
- Accurate data entry and typing skills at 30 WPM minimum
- Ability to work independently and collaboratively
- Must demonstrate honesty, integrity, and professionalism
Working conditions
- Ability to focus on detailed work for long periods of time
- Majority of work time spent using a computer, monitor, and keyboard
- Must be able to work with interruptions and changing priorities
- Ability to work in both onsite and virtual environments
Benefits and perks
- Full-time day shift
- Recognized Magnet hospital environment
- Strong orientation program
- Generous tuition allowance
- Career development opportunities
- Work in a mission-driven organization
Location
New York, US
Employment Type
Full-time
Experience Level
Intermediate Level
Remote work allowed
Yes
Posted
2 weeks ago