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RN Clinical Document Specialist

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Job Details
Job Order Number
Company Name
Trinity Health
Physical Address

Wilmington, DE 19806
Job Description

The Clinical Documentation Improvement Specialist is responsible for performing concurrent review of the patient health record to ensure complete, accurate and specific clinical documentation necessary for understanding the patient’s severity of illness. In this role, the CDI Specialist must adhere to CMS Coding Guidelines to determine the principle diagnosis, principle procedure and all secondary diagnoses. The CDIS is responsible for clarifying conflicting, incomplete, or imprecise documentation by actively querying the responsible Provider during the patient episode. When trends related to documentation of a specific Provider or diagnosis are identified, the CDIS is charged with providing education and training to address the deficit.


Understands, incorporates, and demonstrates the mission, vision, and values of the Ministry, in leadership behaviors, practices, and decisions Understanding of current Clinical Coding and Clinical Documentation guidelines to ensure physician and hospital compliance Adheres to Clinical Documentation Improvement best practices, and defined procedures for record reviews to establish an accurate working DRG, risk or mortality and severity of illness score Stays abreast of Health System policy and industry changes in CDI practices Is well-informed on changes in payment models, documentation requirements, Coding guidelines, and other relevant external directives which impact CDI activities Meets Trinity CDI productivity and quality expectations Effectively identifies cases requiring physician clarification due to conflicting or ambiguous medical record documentation and appropriately and compliantly queries the responsible Provider to gain clarity and specificity Follows-up on outstanding Provider queries when necessary to ensure timely and accurate medical record documentation Confers with Physicians and other involved clinicians to promote timely, accurate and detailed documentation to support a cohesive clinical record Confers with Coding staff concurrently to ensure appropriateness and completeness of supporting documentation and to confirm, when necessary, assignment of a principle diagnosis and secondary diagnoses consistent with coding guidelines. Assists in review and clarification of documentation related to Hospital Acquired Conditions (HAC), and Present on Admission (POA) status Reviews Provider query responses to identify issues with awareness of documentation requirements and provides feedback and guidance when necessary. Utilizes CDI database tools effectively to support ongoing collection of data required to assess performance, report in aggregate, and identify trends. Utilizes hospital EMR appropriately to support record review activities necessary for a thorough understanding of the Patient’s clinical condition and all Caregiver’s clinical impressions Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement. Assists in preparation and presentation of clinical documentation reports for review with Medical Staff and Hospital Leadership. Assists other Departments, such as quality and Accountable care in documentation efforts, when necessary and appropriate Attends, participates in committee activities as directed Performs other duties as assigned


  • Strong understanding of the Catholic health ministry in an evolving health care delivery system and changing reimbursement market.
  • Personal presence that is characterized by a sense of honesty, integrity, and caring as well as the ability to inspire and to motivate others to promote the philosophy, mission, vision, goals, and values of the Ministry.
  • BSN required, or a Bachelor’s in Health Information Management or related field with at least 3-5 years of coding experience, or Associate’s Degree with 5 or more years of Coding or CDI experience. Foreign or Domestic Medical Graduate with 3-5 years CDI experience will be considered.


Job Number: 00165756

Location: Wilmington, DE

Organization Name: Saint Francis Healthcare

Facility: SFDE – St. Francis Healthcare Service

Employment Type: Full time

Hours: 40

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