Position purpose:
This remote Clinical Documentation Improvement (CDI) role focuses on improving the quality, completeness, accuracy, and integrity of medical record documentation. The specialist serves as a reviewer, educator, and consultant, working closely with physicians and other members of the healthcare team to support appropriate code assignment, medical necessity, severity of illness, risk of mortality, and level of services rendered.
Key responsibilities include concurrent chart review, documentation clarification and query development, provider education, collaboration with coding staff, and use of CDI tools such as 3M/360. The role also supports compliance with applicable laws, regulations, and organizational standards.
Qualifications
- Associate or diploma degree in Nursing or Health Information Technology (HIT), or an advanced degree in a nursing or medical field such as MD, DO, NP/APN, or PA
- In the absence of a college degree, at least 3 years of experience as an inpatient coder or clinical documentation specialist
- Preferred credentials include RN license, RHIA, RHIT, CCS, CCDS, or CDIP
- Experience in critical care, medical/surgical inpatient nursing, as an RN, PA, NP/APN, medical school graduate, or inpatient coder preferred
Skills and experience
- Strong communication, interpersonal, collaboration, and relationship-building skills
- Strong critical thinking, problem-solving, prioritization, and organizational skills
- Ability to educate and facilitate learning for healthcare providers and team members
- Familiarity with desktop/Windows systems, email, internet navigation, databases, spreadsheets, and presentation software
- Data entry and typing skills of at least 30 WPM
- Ability to work independently and collaboratively in a stressful, fast-paced environment
- Ability to work in onsite and virtual environments
- Valid driver's license and ability to travel to Trinity Health sites as needed
Location
Michigan, US
Employment Type
Full-time
Experience Level
Senior
Remote work allowed
Yes
Posted
2 weeks ago