Clinical Documentation Specialist RN

Department 10169 Advocate Illinois Masonic Medical Center – Clinical Documentation Improvement Position Details Job Type: Full time Schedule: Hybrid – 3 days onsite, 2 days Work from Home Hours: 40 per week Pay Range: $38.20 – $57.30 Benefits Eligible: Yes Major Responsibilities Conduct chart reviews to improve the overall quality and completeness of clinical documentation using documentation guidelines, evidence‑based practice, and current regulatory requirements. Communicate with healthcare team members to ensure accurate and complete documentation is recorded. Conduct follow‑up reviews to confirm that clarifications and agreed documentation are entered into the patient chart. Identify the most appropriate principal diagnosis and complications with accurate dates to reflect clinical acuity and risk of mortality in compliance with government regulations. Review clinical issues with coding staff to assign a working DRG and follow up with physicians when necessary. Provide daily clinical evaluation of the medical record, including physician and clinical documentation, lab results, diagnostic information, and treatment plan. Confere with physicians, face‑to‑face or via clinical documentation inquiry forms, regarding missing, unclear, or conflicting documentation to clarify information and educate on appropriate documentation of severity of illness. Maintain day‑to‑day evaluation of documentation by the Medical Staff and healthcare team according to hospital policies and procedures. Gather and analyze information pertinent to documentation findings and outcomes. Educate internal customers on clinical documentation opportunities, coding, reimbursement, and performance improvement strategies. Demonstrate knowledge of DRG payer issues, documentation opportunities, clinical documentation requirements, coding, and policies. Develop educational strategies for physicians and other team members regarding identified documentation opportunities. Coordinate education to internal customers on compliance, coding, and documentation issues; act as a consultant to coders when additional information is needed. Participate in continuous performance improvement and complete required educational programs for hospital and medical staff. Maintain knowledge of current standards of care through literature review and educational offerings. Research literature to identify new methods for documentation enhancement. Complete required contact hours based on FTE status within the specified timeframe. Assist the CDI leader in developing and reporting performance measures; prepare physician‑specific data as appropriate. Complete documentation on reviewed cases in the database and complete the DRG and query indicators as appropriate. Promote patient safety by reporting issues through established channels and participating in safety initiatives. Identify patterns, trends, variances, and opportunities to improve documentation review and processes. Maintain a positive attitude toward assignments and team members; promote professional and personal growth by sharing knowledge and resources. Manage stress and personal feelings without a negative impact on the team. Communicate in a positive and productive manner and demonstrate flexibility with changing workload and assignments. Licensure Registered Nurse (RN) Education and Experience Graduate from an accredited school of nursing with a BSN. 5 years of relevant clinical experience (pediatric clinical experience preferred for associate positions). Clinical documentation improvement experience preferred. Current nursing license in the State of Illinois. Certification in clinical documentation improvement preferred. Knowledge, Skills & Abilities Ability to prioritize work. Excellent communication skills (verbal and written). Good problem‑solving and critical thinking skills. Basic computer skills. Effective observer, analytic, and critical thinking abilities. Physical Requirements and Working Conditions Ability to work in a changing environment. Ability to prioritize independently and respond to multiple simultaneous requests. Ability to work under stressful conditions and in difficult situations. May be exposed to hazardous materials and life‑threatening diseases. Requires extensive knowledge and experience of ICD‑10 coding classification system and DRGs. Compensation & Benefits Base compensation within the listed pay range based on qualifications, skills, relevant experience, and/or training. Premium pay such as shift or on‑call pay. Incentive pay for select positions. Opportunity for annual increases based on performance. Paid Time Off programs. Health and welfare benefits (medical, dental, vision, life, short‑ and long‑term disability). Flexible Spending Accounts for eligible health care and dependent care expenses. Family benefits such as adoption assistance and paid parental leave. Defined contribution retirement plans with employer match and other financial wellness programs. Educational Assistance Program. #J-18808-Ljbffr Hugh Chatham Health