Clinical Documentation Specialist (RN)

Department: 10169 Aurora St. Lukes Medical Center - Clinical Documentation Improvement Status: Full time Benefits Eligible: Yes Hours Per Week: 40 Schedule Details/Additional Information: Hybrid role: Three days a week on site, two days remote. Pay Range: $38.20 - $57.30 Clinical Documentation Specialist (RN) Aurora St. Luke’s Medical Center 2900 W. Oklahoma Ave., Milwaukee, WI Aurora St. Luke’s Medical Center is seeking a detail-oriented, clinically experienced Registered Nurse to join our Clinical Documentation Integrity (CDI) team. This role is ideal for nurses who enjoy clinical problem-solving, collaboration with providers, and ensuring the medical record accurately reflects the complexity of patient care. As a Clinical Documentation Specialist, you will serve as a key partner to physicians, nursing staff, and Health Information Management professionals to improve documentation quality, support accurate coding and reimbursement, and ensure the patient's severity of illness is appropriately captured. Where You Will Work Aurora St. Luke’s Medical Center, one of Wisconsin’s premier tertiary care and academic medical centers Hybrid work environment with an expectation to be on-site three days per week Collaborative team environment working closely with physicians, nursing leaders, coders, and clinical staff Opportunity to leverage your clinical expertise in a non-bedside role that directly impacts patient care quality and organizational outcomes We're Looking For Registered Nurses (RN) with a minimum of 2 years of recent clinical nursing experience preference for candidates with ICU or other high-acuity inpatient experience Current Registered Nurse (RN) license issued by the state of Wisconsin in which the team member practices Associate Degree in Nursing (ADN) required Nurses who possess: Strong clinical judgment and critical thinking abilities High-acuity patient care experience and the ability to recognize complex clinical presentations Knowledge and recognition of medications and treatment regimens Strong communication and collaboration skills Comfort working in electronic medical records and Microsoft Word Ability to work independently while partnering effectively with providers and interdisciplinary teams Availability to work on-site two days per week What You Will Do Review inpatient medical records concurrently to ensure accurate, complete, and compliant clinical documentation. Conduct comprehensive chart reviews to identify co-morbidities, complications, quality indicators, and opportunities for documentation improvement. Collaborate with physicians, nurses, and coding professionals to identify principal and secondary diagnoses, procedures, and appropriate DRG assignments. Utilize the physician query process to clarify clinical documentation and accurately reflect patient severity of illness, risk of mortality, and complexity of care. Support quality metrics, reimbursement accuracy, and regulatory compliance through effective documentation practices. Identify, evaluate, and help resolve barriers to meeting clinical documentation standards. Monitor and track Clinical Documentation Integrity (CDI) program outcomes using established tools and reporting processes. Identify quality variances and documentation opportunities that can be addressed concurrently during the patient's admission. Serve as an educator and resource to physicians and clinical staff regarding documentation requirements, best practices, and query responses. Build and maintain positive working relationships across interdisciplinary teams while promoting documentation excellence and problem-solving. About This Location: Aurora St. Luke’s Medical Center is a 938-bed, quaternary acute care community hospital that provides advanced health care expertise. The organization offers leading edge oncology, cardiovascular and neurology therapies for primarily adult patients. Nursing professional governance is a particular organizational strength, with over 40 years of experience in clinical nurse shared decision making. Aurora St. Luke’s has been recognized for Nursing Excellence by the American Nurses Credentialing Center Magnet Recognition Program® since 2001, most recently celebrating our 6th consecutive designation in February 2024. Be the Nurse Who Redefines Care. At Advocate Health, being a nurse means more than delivering exceptional clinical care—it means leading with purpose, compassion, and boldness. As part of our One Advocate Nurse community, you’ll join a unified team committed to lifting others up, embracing innovation, and creating inclusive spaces where everyone can thrive. You’ll be empowered to think boldly, collaborate with humility, and drive change through fearless curiosity. Whether you're at the bedside, in the community, or advancing care through research and education, you’ll help shape the future of health—because here, we’re redefining care for you, for us, for all. Your feedback matters. Every nurse’s voice is vital in shaping our culture and improving care. We value your insights and experiences because they help us grow stronger together. Ready to Take the Next Step: Apply today! Our Commitment to You: Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including: Compensation Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training Premium pay such as shift, on call, and more based on a teammate's job Incentive pay for select positions Opportunity for annual increases based on performance Benefits and more Paid Time Off programs Health and welfare benefits such as medical, dental, vision, life, and 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 Note: Eligibility for programs listed above may depend on your FTE or status (e.g., full-time, part-time, per diem, temporary, etc.); please ask a Recruiter for more information during an interview. About Advocate Health Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits. This is Transformation One shared purpose brought us together. Now, as one of the 10 largest not-for-profit, integrated health systems in the United States, our combined strength and stability drives us forward. Starting with You Caring for nearly 3 million people has inspired a transformation. One in which the patient’s experience guides our vision and empowers us to offer new possibilities in our communities. Reshaping Access What is access? It’s offering more sites of care than any other health system in the Midwest. But there’s a new frontier. Access is exploring the latest technologies to deliver care to patients exactly where they are and exactly when they need it Inspiring Professionals With our dynamically inclusive workforce and strong connections to the places where we live and work, we’ll touch more lives and contribute to stronger and more vibrant communities. Transforming Care We’re redefining the standard for care with world-class doctors and caregivers, innovative solutions, outstanding outcomes, and leading-edge research and clinical trials. Combined, Advocate and Aurora are recognized for clinical excellence in: Cardiovascular Care Neurosciences Gynecology Oncology Pediatrics Primary Care Neurology Geriatrics Trauma Care