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Clinical Documentation Specialist

2 months ago

Minot, North Dakota, United States Trinity Health Full time
Job Title: Clinical Documentation Specialist

This position is responsible for enhancing the quality and accuracy of clinical documentation for inpatient admissions, Same Day Surgery, Observation, and Emergency Trauma Center encounters. The Clinical Documentation Specialist collaborates with physicians, nursing staff, and other healthcare providers to ensure that clinical documentation accurately reflects the severity of illness and services rendered to patients.

Key Responsibilities:
  • Review and modify clinical documentation to ensure accuracy and completeness.
  • Collaborate with physicians and other healthcare providers to resolve documentation discrepancies.
  • Ensure that clinical documentation meets regulatory and accreditation standards.
  • Develop and implement documentation improvement strategies to enhance clinical documentation quality.
  • Provide education and training to healthcare staff on documentation best practices.
Requirements:
  • Current or temporary RN license in ND or compact RN licensure or LPN designation required.
  • Associate or Bachelor's Degree in Nursing or Health Information Management required.
  • A minimum of 3+ years clinical experience in an acute care or outpatient setting required.

Trinity Health is committed to providing high-quality patient care and improving healthcare outcomes. As a Clinical Documentation Specialist, you will play a critical role in ensuring that clinical documentation accurately reflects the severity of illness and services rendered to patients.