Employment Type:Full time
Shift:Description:POSITION PURPOSE
Join our dynamic System Office CDI Float Pool and provide top-tier onsite and remote clinical documentation integrity (CDI) support to Health Ministry (HM) CDI programs. Utilize your advanced coding and clinical expertise to enhance the accuracy and integrity of clinical documentation.
You will be responsible for auditing medical record clinical documentation to validate medical necessity, severity of illness, risk of mortality, accurate coding, clinical evidence, resources consumed, and the level of services provided. Additionally, you'll train end users on CDI system software, standards, and workflow while auditing HM CDSs for query compliance, workflow, and missed documentation opportunities.
ESSENTIAL FUNCTIONS
- Embody and demonstrate Trinity Health's Mission, Vision, and Values in all behaviors, practices, and decisions.
- Facilitate accurate clinical documentation to ensure medical necessity, severity of illness, risk of mortality, accurate coding, clinical evidence, resources consumed, and the level of services are reflected in the health record.
- Conduct clinical documentation chart reviews and query providers as needed to support RHMs staffing needs, either on site or remotely.
- Follow HM CDI Program workflow and processes and communicate with local CDI Team to support operations.
- Engage with physicians and healthcare team members at the HM regarding clinical documentation.
- Audit medical records, queries, CDS and coder assigned codes, CDI software entries, and provide feedback for improvement opportunities.
- Train end users in CDI system software, standards, and workflow.
- Provide documentation education to providers and healthcare team members.
- Quickly learn and master various CDI technology applications, systems, and workflows.
- Offer expertise in problem-solving, drawing on theoretical knowledge, clinical experience, and sound judgment, and serve as a professional role model.
- Assist the System Office Clinical Documentation Manager with all aspects of the CDI program, including data collection and maintenance of the CDI Dashboard.
- Develop educational content on CDI workflow and processes, CDI and Physician software systems, and documentation and coding guidelines.
- Perform other duties as assigned by leadership.
- Maintain knowledge of relevant Federal, State, and local laws and regulations, accrediting agencies, and Trinity Health’s policies and procedures to ensure compliance.
Hourly pay range: $35.6322 - $53.4483
MINIMUM QUALIFICATIONS
- Possess one of the following:
- 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, interpersonal, collaboration, and relationship building skills.
- Strong critical thinking skills and ability to integrate knowledge.
- Prioritization and organizational skills.
- Ability to educate all healthcare team members on clinical documentation.
- Experience with databases, spreadsheet software, and presentation software preferred.
- Comfortable operating independently in a collaborative, shared leadership environment.
- Personal presence characterized by honesty, integrity, and caring with the ability to inspire and motivate others to promote Trinity Health’s philosophy, mission, vision, goals, and values.
PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS
- Ability to set and organize work priorities and adapt to changes frequently.
- Work concurrently on various tasks/projects in a potentially stressful environment with diverse personalities and work styles.
- Comply with Trinity Health policies and procedures.
- Spend the majority of work time utilizing a computer, monitor, and keyboard.
- Perform some lifting and/or pushing/pulling up to 20 pounds.
- Work with interruptions and perform detailed tasks.
- Work on different projects simultaneously and meet deadlines.
- Concentrate and read for extended periods.
- Engage in a variety of physical activities, including walking, standing, balancing, sitting, squatting, and reading, and sit for long periods.
Join Our Team!
Become a vital part of our mission-driven organization and contribute to the enhancement of clinical documentation integrity. Apply your expertise, inspire others, and support the delivery of high-quality healthcare across our system.
The above statements are intended to describe the general nature and level of work being performed by persons assigned to this classification. They are not to be construed as an exhaustive list of duties so assigned.
Our Commitment to Diversity and Inclusion
Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. 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 law.
