RN Clinical Documentation Specialist

Clinical Documentation Specialist

Hourly Pay Range: $38.67 - $59.94 - The hourly pay rate offered is determined by a candidate's expertise and years of experience, among other factors.

The Clinical Documentation Specialist is responsible for improving the overall quality and completeness of clinical documentation to ensure accurate coding, appropriate reimbursement, and compliance with regulatory requirements. This role involves working closely with physicians, healthcare providers, and coding staff to clarify and enhance the documentation of clinical information.

Position Highlights:

• Position: Clinical Documentation Specialist
• Location: Hybrid Skokie, IL and remote
• Full Time/Part Time: Full Time (40 hours per week)
• Hours: Monday-Friday, 8:00am-4:30pm
• Required Travel: required travel to other Endeavor Health locations for in person trainings and meetings

What You Will Do:

• Review medical records concurrently to ensure accuracy, completeness, and specificity of clinical documentation.
• Identify and clarify missing, conflicting, or nonspecific physicians' documentation through queries and follow up.
• Collaborate with healthcare providers to ensure accurate and comprehensive documentation of patient diagnoses and treatments.
• Develop and implement effective query to resolve documentation issues.
• Ensure queries are clear, concise, and compliant with industry's standards and regulatory requirements.
• Track and follow up on outstanding queries to ensure timely responses.
• Query format and questions meet AHIMA and ACIDS guideline.
• Ensures adherence to professional standards, quality standards, licensure, and federal laws.
• Ensure clinical documentation complies with all applicable regulations and standards, including those set by CMS, Joint Commission, and other governing bodies.
• Provide education to the physicians and other clinical staff on documentation best practice and importance of accurate clinical documentation
• Attend education programs, workshops, and one-one-one training to enhance continuous learning.
• Participate in professional organization such as the Clinical Documentation Improvement Specialist (ACDIS) or the American Health Information Management.
• Actively engage in mentoring relationships to support less experienced colleagues and contribute to professional development within the team.

What You Will Need:

• Education: Associate in Nursing or HIM is required. Bachelor's degree in nursing is preferred
• Certification: ADN or RHIT; IL Licensed RN Preferred
• Experience: 3-5 years RN experience in an Acute Care Hospital (critical care preferred)
• Unique or Preferred Skills:
• Strong clinical knowledge and demonstrated commitment to maintaining relevancy in the clinical field.
• Excellent analytical and communication skills.
• Ability to work independently and collaboratively in a team environment.
• Proficient in using electronic medical record (EMR) and clinical tools.
• Familiarity with healthcare regulations, including HIPAA, and documentation standards
• Proficient in using office software (e.g., Microsoft Office Suite, excel) and other communication platforms (e.g., email, video conferencing) for collaboration and reporting.

Benefits (For full time or part time positions):

• Opportunity for annual increases based on performance
• Career Pathways to Promote Professional Growth and Development
• Various Medical, Dental, Pet and Vision options
• Tuition Reimbursement
• Free Parking
• Wellness Program Savings Plan
• Health Savings Account Options
• Retirement Options with Company Match
• Paid Time Off and Holiday Pay
• Community Involvement Opportunities

Endeavor Health is a fully integrated healthcare delivery system committed to providing access to quality, vibrant, community-connected care, serving an area of more than 4.2 million residents across six northeast Illinois counties. Our more than 25,000 team members and more than 6,000 physicians aim to deliver transformative patient experiences and expert care close to home across more than 300 ambulatory locations and eight acute care hospitals Edward (Naperville), Elmhurst, Evanston, Glenbrook (Glenview), Highland Park, Northwest Community (Arlington Heights) Skokie and Swedish (Chicago) all recognized as Magnet hospitals for nursing excellence.

When you work for Endeavor Health, you will be part of an organization that encourages its employees to achieve career goals and maximize their professional potential.

Endeavor Health is committed to working with and providing reasonable accommodation to individuals with disabilities. Please refer to the main career page for more information.

At Endeavor Health, we are united by a shared commitment to working together to create a culture of connection and belongingeach of us bringing different skills and experiences as we deliver safe, seamless, and personal care. Every person, every time. We are committed to fostering an environment where all team members can be their best, learn, and pursue excellence together.

EOE: Race/Color/Sex/Sexual Orientation/ Gender Identity/Religion/National Origin/Disability/Vets, VEVRRA Federal Contractor.