Clinical Documentation Specialist II

Employment Type

• Full time
• Shift:
• Day
• Shift
• Description: Utilizes advanced coding and/or clinical expertise to direct efforts toward the improvement of clinical documentation through the roles of educator and consultant. Facilitates improvement in the overall quality, completeness, and accuracy 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 the medical necessity and level of services rendered to all patients. Participates in the development and delivery of education for providers and members of the healthcare team.
• What the
• Clinical
• Documentation
• Specialist
• II will do: Demonstrates understanding of and facilitates 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 quality 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 participation. 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. Collaborates with coding staff to assure 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.

Minimum Qualifications

Must possess a comprehensive knowledge of acute care nursing experience, as normally obtained through a Bachelor of Science, Nursing (BSN) and five (5) years on a medical or surgical unit, or Bachelor of Science in Health Information Management (HIM) and five (5) years HIM/inpatient coding experience, or an Associate/Diploma Degree in Nursing and ten (10) years on a medical or surgical unit, or an Associate Degree in Health Information Technology or in a related healthcare field. Ten (10) years' experience in acute inpatient coding preferred Current Registered Nurse License in the State of practice, Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), or Certified Coding Specialist (CCS). Certified Clinical Documentation Specialist (CCDS) preferred. Experience in Critical Care, Utilization Management/Case Management, Clinical Documentation, ICD-9 Coding Guidelines and DRG assignment or patient outcomes/quality management, preferred. 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. 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 You can also follow Trinity Health on LinkedIn.