**Employment Type:** Full time **Shift:** Day Shift **Description:** **Job Title:** Clinical Documentation Specialist **Location:** Remote **Job Type:** Full-Time **Department:** Health Information Management **Reports To:** Reg Manager Clinical Documentation Integrity **Position Summary** We are seeking a highly skilled and detail-oriented **Clinical Documentation Specialist** to join our team. This role leverages advanced clinical and/or coding expertise to enhance the quality, accuracy, and completeness of medical record documentation. As an educator and consultant, you will collaborate with physicians and healthcare professionals to ensure documentation reflects the true severity of illness, risk of mortality, and level of care provided. **What You’ll Do** + Conduct concurrent reviews of patient records to ensure clarity, completeness, and precision in clinical documentation. + Collaborate with physicians and healthcare teams to improve documentation practices and ensure accurate reflection of patient care. + Serve as a subject matter expert and resource for clinical documentation standards and best practices. + Provide education and training to providers and staff on documentation improvement opportunities. + Partner with coding teams to ensure accurate DRG assignment and coding compliance. + Identify and address documentation discrepancies in a professional and timely manner. + Support quality outcomes through improved documentation and data integrity. **What You’ll Need** + **Education & Experience:** + BSN with 5+ years of acute care experience (medical/surgical unit), or + BS in Health Information Management with 5+ years of HIM/inpatient coding experience, or + Associate/Diploma in Nursing with 10+ years of acute care experience, or + Associate in Health Information Technology or related field with 10+ years of inpatient coding experience (preferred). + **Licensure/Certifications:** + Active RN License, RHIA, RHIT, or CCS required. + CCDS certification preferred. + **Preferred Experience:** + Background in Critical Care, Utilization/Case Management, Clinical Documentation, ICD-9/10 Coding, DRG assignment, or Quality Management. + **Skills:** + Strong verbal and written communication skills. + Excellent critical thinking and analytical abilities. + Effective collaboration and relationship-building skills. + Ability to educate and influence clinical staff. + Strong organizational and prioritization skills. **Why Join Us?** You’ll be part of a mission-driven organization committed to excellence in patient care and clinical outcomes. We offer a collaborative environment, opportunities for professional growth, and a chance to make a meaningful impact on healthcare quality. **Apply now through Workday to join our team and help shape the future of clinical documentation excellence.** **Our Commitment** Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are 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, veteran status, 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. EOE including disability/veteran