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Clinical Documentation Specialist, Audit Coordinator

Remote, USA Full-time Posted 2025-11-24
Job Description: • Provides onsite and remote clinical documentation integrity (CDI) support to the Health Ministry (HM) CDI programs as part of the System Office CDI Float Pool. • Utilizes advanced coding and/or clinical expertise to direct efforts toward the improvement and integrity of clinical documentation. • Responsible for reviewing and/or auditing medical record clinical documentation to support the medical necessity, severity of illness, risk of mortality, accurate coding, clinical evidence, resources consumed, and level of services rendered to all patients. • Audits HM CDSs for query compliance, workflow and missed documentation opportunities. • Trains end users in the use of CDI system software, standards, and workflow. • Conducts clinical documentation chart reviews and queries providers as appropriate to support RHMs staffing needs. • Follows HM CDI Program workflow and processes and communicates with local CDI Team to support local operations. • Provides documentation education to providers and members of healthcare team at the RHM as part of CDI Team assignment or as requested. • Assists the System Office Clinical Documentation Manager with all aspects of the CDI program across the system including data collection and maintenance of the CDI Dashboard. • Performs other duties as assigned by leadership. Requirements: • 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 (verbal and written), interpersonal, collaboration and relationship-building skills. • Strong critical thinking skills and ability to integrate knowledge. • Prioritization and organizational skills required. • Ability to educate all members of the healthcare team related to clinical documentation. • Experience with databases, spreadsheet software and presentation software preferred. • Must be comfortable operating independently in a collaborative, shared leadership environment. • Must possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Trinity Health. Benefits: Apply tot his job Apply To this Job

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