Clinical Documentation Specialist (RN)

Clinical Documentation Specialist (RN) – Aurora St. Luke’s Medical Center, 2900 W. Oklahoma Ave., Milwaukee, WI. Department: 10169 Aurora St. Lukes Medical Center – Clinical Documentation Improvement State: Full time, Benefits Eligible: Yes Hours per Week: 40 Hybrid Schedule: Three days on site, two days remote Pay Range: $38.20 – $57.30 We are 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. Responsibilities 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. Qualifications Registered Nurse (RN) with a minimum of 2 years of recent clinical nursing experience; preference for ICU or other high‑acuity inpatient experience. Current RN license issued by the state of Wisconsin. Associate Degree in Nursing (ADN) required; Bachelor’s degree preferred. Strong clinical judgment and critical thinking abilities. High‑acuity patient care experience and 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. Benefits Competitive compensation within the stated pay range; possible premium pay (shift, on‑call) and incentive pay for select positions; opportunity for annual increases based on performance. Paid Time Off programs. Health and welfare benefits including 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. #J-18808-Ljbffr