Clinical Documentation Specialist - Full Time - Days (Remote) at Trinity Health Michigan

Posted in Other 4 days ago.

Location: Pontiac, Michigan

Job Description:

Employment Type:

Full time


Day Shift


Utilizes advanced knowledge and clinical expertise to direct efforts toward the improvement of clinical documentation and quality improvement through the roles of educator and consultant. Assists with facilitating improvement in the overall quality, completeness, and accuracy of medical record documentation to improve key clinical processes and outcomes. Through extensive interaction with physicians, nursing staff, and other patient caregivers, achieves appropriate clinical documentation to support the medical necessity and level of services rendered to all patients. Assists with development and delivery of education for all members of the patient care team on documentation guidelines, issues on an ongoing basis.

  • **This is a remote working position**


    • Provides technical assistance to appropriate service lines performing quality activities including, but not

    limited to:

    - Participating in development and design of improvement activities and standards

    - Participating in design of data collection tools and procedures, including planning, measuring and

    assessing the effect of improvement activities

    - Analyzing, collection and tabulation go appropriate primary and secondary sources of importation.

    - Displaying data in a meaningful and useful format.

    - Attending meetings to assist in the interpretation of quality improvements studies

    • Utilizes advanced knowledge of functional health patterns physiology, pathophysiology, and psycho sociology in documentation efforts and other projects related to Outcomes Management.

    • Demonstrates expertise in problem-solving skills based on theoretical knowledge, clinical experience and sound judgment and serves as a professional role model by demonstrating desirable practice behaviors.

    • Serves as a resource for clinical documentation and provides support to associates regarding complex patient issues and the impact on clinical documentation needs; provides consultative services to medical and nursing staff related to documentation and core clinical indicators

    • Establishes collaborative practice and maintains open communication with other nursing personnel, physicians and health care professionals regarding clinical documentation.

    • Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with physician have been recorded in the patient's chart.

    • Facilitates the acquisition and application of clinical, theoretical and financial knowledge and decision-making skills of department staff, physicians, and other health care provides.

    • Assesses learning needs, designs, implements and evaluates systems/processes for health care providers to improve patient outcomes.

    • Evaluates and integrates appropriate research findings into clinical documentation practices as appropriate.

    • Demonstrates continuing expertise in data management and analysis.



    Bachelor of Science, Nursing (BSN) or Bachelor of Science in Health Information Management..

    Credentials/Licensure: Current Registered Nurse License in the State of Michigan or Registered Health Information Administrator (RHIA).

    Related Experience: Minimum of seven (five) years of clinical experience as an RN; acute care experience preferred. . Quality improvement experience preferred (including Lean/Six Sigma, A3etc)

    Other Knowledge, Skills and Abilities: Excellent communication, interpersonal, collaboration and customer relations skills. Ability to analyze data for patterns and trends. Strong critical thinking skills and ability to integrate knowledge. Prioritization and organizational skills required. Ability to educate all members of care team related to clinical documentation. Able to work independently as well as in a team setting.

    Computer Competency: Demonstrates competency using a standard desktop and windows based computer system, including a basic understanding of email, e-learning, intranet and computer navigation. Computer proficiency in PowerPoint, Word and Excel. Demonstrated knowledge and skills in using databases to access key data elements.

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.
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