Clinical Documentation Specialist RN

Where You Will Work :

Advocate Condell offers a full spectrum of medical services and is the largest health care provider and only Level 1 trauma center in Lake County, IL. It is also home to Lake County’s first and only comprehensive Trauma Recovery Center and features an emergency department accredited in geriatric and pediatric care.

We’re Looking For:

Licensure or Certifications

• Registered Nurse

Degrees:

• Graduate from an accredited school of nursing BSN 5 years relevant clinical experience (For associates in process level 25013, 5 years relevant pediatric clinical experience)
• Clinical documentation improvement experience preferred

What You’ll Do: Ensure clinical documentation accurately reflects patient conditions and care provided, supporting quality outcomes, regulatory compliance, appropriate reimbursement, and organizational performance.

• Schedule: Hybrid position 3 days on site and 2 days remote

Core Responsibilities

Clinical Documentation Review and Improvement

• Perform daily reviews of medical records, including physician documentation, lab results, diagnostic testing, and treatment plans.
• Evaluate documentation for accuracy, completeness, severity of illness, risk of mortality, and compliance with clinical documentation standards and regulations.
• Identify opportunities for documentation improvement and ensure the most appropriate principal diagnosis, complications, and comorbidities are captured.
• Conduct follow-up reviews to ensure documentation clarifications have been completed and reflected in the patient record.

Physician and Healthcare Team Collaboration

• Collaborate with physicians and healthcare team members to clarify missing, conflicting, or incomplete documentation.
• Utilize clinical documentation queries and direct communication to obtain necessary documentation.
• Educate providers on documentation practices that support accurate representation of patient acuity and outcomes.
• Foster strong working relationships with physicians, coders, leadership, and other stakeholders.

Coding, DRG, and Regulatory Support

• Review clinical records with coding staff to establish working DRGs and ensure accurate code assignment.
• Serve as a resource and consultant to coders when additional documentation is needed.
• Maintain expertise in DRG methodologies, reimbursement requirements, coding guidelines, and regulatory standards.
• Support compliance with government regulations and organizational policies.

Education and Performance Improvement

• Develop and deliver education for physicians, coders, and clinical staff regarding documentation requirements, coding implications, and reimbursement issues.
• Research best practices and emerging trends in clinical documentation improvement.
• Participate in continuous performance improvement initiatives and required professional development activities.
• Maintain current knowledge through literature review and continuing education.

Data Management and Reporting

• Document case reviews and maintain CDI database records.
• Track DRG assignments, query activity, provider responses, and documentation outcomes.
• Analyze trends, variances, and opportunities for improvement in documentation processes.
• Assist CDI leadership in developing performance metrics, reports, and physician-specific feedback.

Professionalism and Teamwork

• Demonstrate effective communication, professionalism, and collaboration with all team members.
• Maintain a positive attitude, adaptability, and flexibility in managing changing priorities.
• Support team development by sharing knowledge and resources.
• Promote patient safety and participate in organizational quality and safety initiatives.

Key Competencies

• Clinical documentation improvement expertise
• Medical record analysis
• Physician engagement and education
• ICD coding and DRG knowledge
• Regulatory compliance
• Data analysis and reporting
• Performance improvement methodologies
• Communication and relationship management
• Critical thinking and problem-solving

Your feedback matters. Every teammate’s voice is vital in shaping our culture and improving care. We value your insights and experiences because they help us grow stronger together.

Physical Requirements and Working Conditions

• Ability to work in 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
• This position needs to recognize needs and behaviors of specific age groups of patients treated.
• Extensive knowledge and experience of ICD-10 coding classification system and DRGs
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Ready to Take the Next Step:

Apply Now!

his job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.