Trinity Health Of New England · 19 hours ago
CLINICAL DOCUMENTATION SPECIALIST
Hartford, CT
Full-time
Onsite
Entry, Mid Level
2+ years expTrinity Health Of New England is an integrated health care delivery system dedicated to providing comprehensive preventive, acute, and post-acute care. The Clinical Documentation Specialist will utilize clinical and coding expertise to ensure the integrity and quality of clinical documentation, while collaborating with healthcare teams to improve documentation practices and support accurate coding.
HealthcareHospitalHealth CareMedical
Responsibilities
Assist in overall quality, timeliness and completeness of the health record to ensure appropriate data, provider communication and quality outcomes
Communicate with and educates physicians and all other members of the healthcare team regarding clinical documentation and monitors provider engagement
Conduct concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency and precision of clinical documentation
Proficient with leveraging the functions of 3M/360 for entering data related to CDI efficiencies and effectiveness
Maintain a working knowledge of applicable Federal, State and local laws and regulations and accrediting agencies
Collaborate with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care
Qualification
Required
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
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
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
Preferred
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
Benefits
Great benefits and Health Insurance Coverage
Company
Trinity Health Of New England
Trinity Health Of New England is an hospital and integrated health care delivery system.
10001+ employees
Funding
Current Stage
Late StageLeadership Team
Reginald Eadie
President, Chief Executive Officer
Recent News
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