Full timeDay Shift
Come join our Health Information Management team at Saint Francis Hospital, a member of Trinity Health Of New England! We are part of the nationwide Trinity Health family bringing compassionate care to our communities.
This position may be fully remote
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The Clinical Documentation Specialist utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant. Facilitates the overall quality, completeness, accuracy and integrity of medical record documentation through extensive record review.
Through extensive interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients. Participates in the development and delivery of education for providers and members of the healthcare team.
Top Reasons to Work at Trinity Health of New England:
Our Mission and Core Values
Great benefits and Health Insurance Coverage
Career growth and advancement potential
Award-winning Hospitals and Departments
Work Hours/Shift:
Full time 40hrs M-F days
You Will Be Responsible For :
Exceptional Patient Care : Demonstrates understanding of appropriate clinical documentation, to ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record. Assists in overall quality, timeliness and completeness of the health record to ensure appropriate data, provider communication and quality outcomes. Serves as a resource for appropriate clinical documentation.
Excellent Communicator : Communicates with and educates physicians and all other members of the healthcare team regarding clinical documentation and monitors provider engagement. Identifies learning opportunities for healthcare providers.
Strong Educator: Conducts concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency and precision of clinical documentation.
Technical Familiarity: Proficient with leveraging the functions of 3M/360 for entering data related to CDI efficiencies and effectiveness. Maintains a working knowledge of applicable Federal, State and local laws and regulations, accrediting agencies, Trinity Health’s Organizational Integrity Program, Standards of Conduct, Code of Ethics
Active Teamwork : Collaborates with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care. Resolves all discrepancies in a courteous manner.
Requirements :
Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) OR an Advanced degree in nursing or medical field such as NP/APN or PA.
Must possess one of the below:
Current Registered Nurse License in the State of practice,
Registered Health Information Administrator (RHIA),
Registered Health Information Technician (RHIT),
Certified Coding Specialist (CCS) required,
licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APN) or completion of medical school.
Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred.
Two (2) years experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), medical school graduate or as an inpatient coder preferred.
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. Effective presentation/facilitation skills to accomplish educational goals for all members of the healthcare team.
About Trinity Health Of New England:
Trinity Health Of New England is an integrated health care delivery system that is comprised of world-class providers and facilities dedicated to full spectrum preventative, acute, and post-acute care. We aim to deliver top level care to increase our community's overall health at lower costs. While we serve nearly 3 million people, we are proud to be a part of a national system that focuses on putting our patients first and having the best colleagues to do so.
Trinity Health Of New England benefits include health insurance, adoption assistance, tuition reimbursement, paid vacation, sick time, and professional advancement just to name a few.
Employees can also take advantage of extra benefits specific to each hospital.
Step up to your potential. Write your story and apply today!
Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by federal, state or local law.
Our Commitment to Diversity and Inclusion
Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.