Clinical Documentation Specialist II
Apply NowLocation:
Grand Rapids, MI, US
Company:
Trinity Health is one of the largest not-for-profit, faith-based health care systems in the nation, providing diverse health services across 27 states.
Summary:
The Clinical Documentation Specialist II ensures the quality and accuracy of clinical documentation while collaborating with healthcare teams. Candidates must have relevant nursing or health information degrees and experience in acute care or coding.
Requirements:
Credentials: Bachelor of Science in Nursing (BSN), Bachelor of Science in Health Information Management (HIM), Associate/Diploma in Nursing, Associate degree in Health Information Technology or related healthcare field
Experience: 5 years of acute care nursing experience, 5 years of HIM/inpatient coding experience, 10 years of medical/surgical nursing experience, 10 years of inpatient coding experience preferred
Job Description:
Clinical Documentation Specialist II
- time type
- Full time
- posted on
- Posted Yesterday
- job requisition id
- 00599289
Employment Type:
Full time
Shift:
Day Shift
Description:
Job Title: Clinical Documentation Integrity Specialist
Location: Remote
Employment Type: Full-Time
Position Summary
The Clinical Documentation Integrity (CDI) Specialist utilizes advanced clinical and/or coding expertise to enhance the quality, completeness, and accuracy of clinical documentation in the medical record. This role acts as both an educator and a consultant, collaborating closely with physicians and the healthcare team to ensure documentation appropriately reflects the severity of illness, risk of mortality, and level of service provided.
The CDI Specialist conducts detailed record reviews and serves as a resource to improve documentation practices, ensuring compliance and accurate reflection of patient care. This position supports the organization’s goals for quality outcomes, clinical excellence, and operational integrity.
What You Will Do
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Perform concurrent reviews of health records to assess the clarity, completeness, and accuracy of documentation.
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Facilitate improvements in clinical documentation to better reflect the patient’s clinical status and medical necessity.
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Educate and consult with physicians and healthcare providers on documentation best practices and requirements.
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Collaborate with coding teams to ensure accurate DRG assignment and diagnosis capture.
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Monitor provider participation and identify learning opportunities for ongoing education.
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Assist with the development and delivery of documentation-related education to providers and care teams.
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Provide support and problem resolution to team members as needed.
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Serve as a subject matter expert on documentation standards, coding guidelines, and clinical relevance.
What You Will Need
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Bachelor of Science in Nursing (BSN) with 5 years of acute care nursing experience, or
Bachelor of Science in Health Information Management (HIM) with 5 years of HIM/inpatient coding experience, or
Associate/Diploma in Nursing with 10 years of medical/surgical nursing experience, or
Associate degree in Health Information Technology or related healthcare field with 10 years of inpatient coding experience preferred -
One of the following current certifications is required:
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Registered Nurse (RN) License (state-specific)
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Registered Health Information Administrator (RHIA)
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Registered Health Information Technician (RHIT)
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Certified Coding Specialist (CCS)
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Certified Clinical Documentation Specialist (CCDS) preferred
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Experience in Critical Care, Utilization/Case Management, Clinical Documentation Improvement, ICD coding, DRG assignment, or Quality Management preferred
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Strong communication, collaboration, and critical thinking skills
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Excellent organizational, time management, and facilitation abilities
Why Join Us
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Day 1 Benefits – Medical, dental, vision, PTO, and 403(b)
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DailyPay – Access your pay when you need it
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Career Growth – Opportunities across our nationwide health system
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A culture grounded in compassion, inclusion, and excellence
Apply now to join a team dedicated to quality, compliance, and transforming clinical documentation to reflect the highest standards of patient care.
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.
About Us
Trinity Health is one of the largest not-for-profit, faith-based health care systems in the nation. Together, we’re 121,000 colleagues and nearly 36,500 physicians and clinicians caring for diverse communities across 27 states. Nationally recognized for care and experience, our system includes 101 hospitals, 126 continuing care locations, the second largest PACE program in the country, 136 urgent care locations, and many other health and well-being services. Based in Livonia, Michigan, in fiscal year 2023, we invested $1.5 billion in our communities through charity care and other community benefit programs.
For more information, visit http://www.trinity-health.org. You can also follow Trinity Health on LinkedIn.
