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Last updated: 1 day ago

Clinical Documentation Specialist, REMOTE

Trinity HealthAthens, Georgia, 30606-3791
Remote
Full-time

Position requires current RN license or CCS or RHIT with Inpatient Coding experience.This position will be based at St.Mary's Sacred Heart Hospital in Lavonia, Georgia.The Clinical Documentation Sp... Show more

Telemarketer - State Farm Agent Team Member

Shane Dekle - State Farm AgentAthens, GA, US
$15.00 hourly
Full-time

We are currently seeking a dynamic and enthusiastic Telemarketer to join our team.As a Telemarketer, you will play a crucial role in expanding our client base and promoting our insurance products a... Show more

Junior AI /Machine learning engineer/Data scientist/Java developer

SynergisticITAthens, GA, US
Full-time

You have solved 500+ Leetcode Problems! —Still No Offers? Let's Get You Hired with a plan which actually works.You've racked up certificates, aced LeetCode challenges, and you know your way around ... Show more

Power BI Publisher / Power BI Developer

Delan Associates, IncAthens, Georgia, United States
Full-time

We are seeking an experienced Power BI Developer/Publisher to support a large-scale reporting and analytics modernization initiative.The primary focus of this role is migrating legacy IBM Cognos re... Show more

Site Development Project Manager

HillpointeAthens, GA, United States
Permanent

Site Development Project Manager.Hillpointe is a fully integrated real estate development and investment management firm focused on developing market-rate workforce housing across the Sun Belt.Rank... Show more

Civil Engineer - Senior Site Design or Project Manager

Genesis Management Consulting GlobalAthens, GA, United States
Full-time

Senior Civil Engineer (Civil Site Design).We are Recruiting on Purpose for a Senior Civil Engineer (Civil Site Design) for our client in Athens, GA!.Terrific Mid-size Engineering Firm.A GREAT PLACE... Show more

Part Time Showroom Assistant

AlloraAthens, GA, US
Part-time
Quick Apply

Our client, Hawthorne House, is hiring for a part-time Showroom Assistant.This position is a vital role for Hawthorne House.The ideal candidate must be able to work with clients on the showroom flo... Show more

IT Support - Entry Level Training Program

Dreambound Inc.Athens-Clarke County unified government, Georgia, United States
Full-time

Note : This is an educational program, not a job.Successful completion of the program does not guarantee employment but will equip you with valuable skills for the IT job market.Looking to start a ... Show more

Angular/NodeJS Developer - II

Syms Strategic Group, LLC (SSG)Athens, GA, US
$85,389.00 yearly
Full-time
Quick Apply

Syms Strategic Group (SSG)  is seeking a talented Senior Systems Engineer (Angular) Location:.Remote Department: Veterans Affairs (VA) Type:  Full Time Min.Experienced Security Clearance ... Show more

Leasing Consultant

Stonemark Management LLCAthens, GA, United States
Full-time

Markets, shows and leases apartments to prospective tenants.Responds to all applicants and residents in a courteous and prompt manner regarding leasing, marketing, and resident relations.The activi... Show more

Sr. ServiceNow Developer

Orison SolutionsAthens, GA, Georgia, USA
Full-time

ServiceNow Developer<br /> Location:- Athens, GA (Remote)<br /> Duration:- 12+ Months<br /> NOTE:- Local candidates given first preference, but 100% remote is acceptable.Job Descr... Show more

Project Superintendent Luxury Custom Homes

Skillforce, Inc.Athens, GA, United States
Full-time

Project Superintendent Luxury Custom Homes.Skillforce has teamed up with a fast growing developer to find a Project Superintendent Luxury Custom Homes.This person will be working on projects arou... Show more

Absence Management Consultant

BizTek PeopleAthens, GA, United States
$10.00 hourly
Part-time

The Absence Management Consultant will conduct/document Business Process Requirements, facilitate Fit/Gap sessions to determine configuration and identify potential customization (with a goal of mi... Show more

bealls Merchandise Supervisor

beallsAthens, GA, US
Full-time

Come join a team that brings a people-first approach to everything we do! bealls and Home Centric are a part of Bealls Inc.We Outfit the Family for Less”.Being a growing organization with our eye t... Show more

Dental Assistant

Bartram Family Dental CareAthens, GA, United States
Full-time

Dental Assistant Gaines View Dental Care is looking for a Dental Assistant to join our team.This is where patients come first, and continuous learning is encouraged! Hard-working and motivated, the... Show more

Java Developer

eliteworkforceincAthens, GA
Full-time

Core Java, J2EE, Spring, Hibernate – min 4yrs (must have).PLSQL, front end like HTML, java script etc.Working knowledge on Vertx is added advantage.Core Java, J2EE, Spring, Hibernate, Session manag... Show more

Remote Software Developer $60 - $120/hourpay

Micro1Athens, Georgia, US
$60.00 hourly
Remote
Full-time

AI data lab for training frontier models and evaluating AI agents.Experts contribute their diverse subject matter knowledge across domains such as finance, healthcare, STEM engineering, and more.AI... Show more

 • Promoted

Automation Controls Engineer

GpacAthens, Georgia, United States
Full-time
Quick Apply

Our client is a privately owned, rapidly growing company seeking an.This role involves creating detailed designs using CAD software, sketches, specifications, and engineering notes.For nearly a dec... Show more

Content Creator

Cache VenturesAthens, GA, US
Remote
Full-time
Quick Apply

We’re seeking a creative content creator to drive revenue growth.This role requires a candidate with a proven track record in managing social media, creating compelling content, and leading innovat... Show more

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Clinical Documentation Specialist, REMOTE

Clinical Documentation Specialist, REMOTE

Trinity HealthAthens, Georgia, 30606-3791
2 days ago
Job type
  • Full-time
  • Remote
Job description

Employment Type:

Full time

Shift:

Day Shift

Description:Full time, Monday thru Friday. Position requires current RN license or CCS or RHIT with Inpatient Coding experience. This position will be based at St. Mary's Sacred Heart Hospital in Lavonia, Georgia.

The Clinical Documentation Specialist utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant. Facilitates the overall quality, completeness, accuracy and integrity of medical record documentation through extensive record review.

Through extensive interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients. Participates in the development and delivery of education for providers and members of the healthcare team.

PRIMARY JOB RESPONSIBILITIES AND DUTIES:

Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, standards, policies, procedures and decisions. Demonstrates understanding of appropriate clinical documentation, to ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record. Assists in overall quality, timeliness and completeness of the health record to ensure appropriate data, provider communication and quality outcomes. Serves as a resource for appropriate clinical documentation. Communicates with and educates physicians and all other members of the healthcare team regarding clinical documentation and monitors provider engagement. Identifies learning opportunities for healthcare providers. Conducts concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency and precision of clinical documentation. Formulates compliant clarifications/queries following Trinity Health’s documentation integrity procedures. Interacts with physicians, nurses and ancillary staff regarding compliant documentation requirements, clarification/query requests and educational opportunities. Accurately codes all relevant, appropriate and compliant working diagnoses codes, establishing a working principle diagnosis and working DRG (MS or APR). Collaborates with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care. Resolves all discrepancies in a courteous manner. Demonstrates expertise in problem-solving skills based on theoretical knowledge, clinical experience and sound judgement and serves as a professional role model by demonstrating desirable practice behaviors. Proficient with leveraging the functions of 3M/360 for entering data related to CDI efficiencies and effectiveness. Performs other duties as assigned by leadership. Maintains a working knowledge of applicable Federal, State and local laws and regulations, accrediting agencies, Trinity Health’s Organizational Integrity Program, Standards of Conduct, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.

MINIMIUM QUALIFICATIONS, REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:

Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) OR and Advanced degree in nursing or medical field such as NP/APN or PA. Must possess one of the below:

Current Registered Nurse License in the State of practice,

Registered Health Information Administrator (RHIA),

Registered Health Information Technician (RHIT),

Certified Coding Specialist (CCS) required,

licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APN) or completion of medical school.

Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred. Two (2) years experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), medical school graduate or as an inpatient coder preferred. 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. Effective presentation/facilitation skills to accomplish educational goals for all members of the healthcare team. Demonstrated ability to use a standard desktop and Windows based computer system, including a basic understanding of email, internet and computer navigation. Ability to use other software as required to perform the essential functions on the job. Experience with databases, spreadsheet software and presentation software preferred. Accurate data entry skills and typing skills at minimum 30 wpm. Must be comfortable operating independently and in a collaborative 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.

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.