Clinical Documentation Specialist, Audit Coordinator
Job Description:
• Provides onsite and remote clinical documentation integrity (CDI) support to the Health Ministry (HM) CDI programs as part of the System Office CDI Float Pool.
• Utilizes advanced coding and/or clinical expertise to direct efforts toward the improvement and integrity of clinical documentation.
• Responsible for reviewing and/or auditing medical record clinical documentation to support the medical necessity, severity of illness, risk of mortality, accurate coding, clinical evidence, resources consumed, and level of services rendered to all patients.
• Audits HM CDSs for query compliance, workflow and missed documentation opportunities.
• Trains end users in the use of CDI system software, standards, and workflow.
• Conducts clinical documentation chart reviews and queries providers as appropriate to support RHMs staffing needs.
• Follows HM CDI Program workflow and processes and communicates with local CDI Team to support local operations.
• Provides documentation education to providers and members of healthcare team at the RHM as part of CDI Team assignment or as requested.
• Assists the System Office Clinical Documentation Manager with all aspects of the CDI program across the system including data collection and maintenance of the CDI Dashboard.
• Performs other duties as assigned by leadership.
Requirements:
• Current Registered Nurse License, Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS) Certification as a Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred.
• Experience in Clinical Documentation Integrity.
• 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.
• Ability to educate all members of the healthcare team related to clinical documentation.
• Experience with databases, spreadsheet software and presentation software preferred.
• Must be comfortable operating independently in a collaborative, shared leadership environment.
• Must possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Trinity Health.
Benefits:
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• Provides onsite and remote clinical documentation integrity (CDI) support to the Health Ministry (HM) CDI programs as part of the System Office CDI Float Pool.
• Utilizes advanced coding and/or clinical expertise to direct efforts toward the improvement and integrity of clinical documentation.
• Responsible for reviewing and/or auditing medical record clinical documentation to support the medical necessity, severity of illness, risk of mortality, accurate coding, clinical evidence, resources consumed, and level of services rendered to all patients.
• Audits HM CDSs for query compliance, workflow and missed documentation opportunities.
• Trains end users in the use of CDI system software, standards, and workflow.
• Conducts clinical documentation chart reviews and queries providers as appropriate to support RHMs staffing needs.
• Follows HM CDI Program workflow and processes and communicates with local CDI Team to support local operations.
• Provides documentation education to providers and members of healthcare team at the RHM as part of CDI Team assignment or as requested.
• Assists the System Office Clinical Documentation Manager with all aspects of the CDI program across the system including data collection and maintenance of the CDI Dashboard.
• Performs other duties as assigned by leadership.
Requirements:
• Current Registered Nurse License, Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS) Certification as a Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred.
• Experience in Clinical Documentation Integrity.
• 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.
• Ability to educate all members of the healthcare team related to clinical documentation.
• Experience with databases, spreadsheet software and presentation software preferred.
• Must be comfortable operating independently in a collaborative, shared leadership environment.
• Must possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Trinity Health.
Benefits:
Apply Now
Apply Now