Clinical Documentation Specialist

Job Description

Be a part of a world-class academic healthcare system at UChicago Medicine as a Clinical Documentation Specialist - Inpatient for the Medical Records Department . This position is hybrid and requires travel to our Hyde Park Campus in Chicago, IL as needed.


The Clinical Documentation Specialist is responsible for facilitating improvement in the overall quality and completeness of medical record documentation on a concurrent basis. In this role, the Clinical Documentation Specialist - Inpatient promotes modifications to medical record documentation to ensure accurate depiction of the level of clinical services provided to the patient and to completely describe patients' severity of illness. The CDS obtains appropriate clinical documentation through collaborative communications from having developed positive working relationships with physicians, nursing staff, other patient care providers, and the Health Information Management Department Coders. The CDS is also responsible for providing informal and formal education to all members of the care team regarding clinical documentation.

Essential Job Functions

• Communicates with attending physician(s) verbally and through written methodology to validate observations, and obtain clarification of incomplete, unclear, and ambiguous documentation including clarification of POA.
• Demonstrates and applies basic knowledge of documentation requirements and guidelines in accordance with ICD-10 CM Official Guidelines for Coding and Reporting.
• Consistently meets established productivity targets for record review.
• In collaboration with physician leadership, designs and implements specific tools to support physician documentation requirements.
• Maintains the confidentiality of information acquired pertaining to patients, physicians, associates, and visitors.
• Discusses patient and hospital information only among appropriate personnel in private and appropriate settings.
• Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of co-workers, and to report all preventable hazards and unsafe practices immediately to management.

Required Qualifications

• Analytic skills necessary to clinically assess medical records
• Bachelor's Degree
• IL RN License
• Basic computer skills in word processing and spreadsheet utilization
• Excellent interpersonal skills necessary to develop and foster effective physician communication

Preferred Qualifications

• 5-8 years' experience in Case Management or Med/Surg or Critical Care nursing experience
• Master's Degree
• CCS coding credential

Position Details

• Job Type/FTE: Full Time (1.0 FTE)
• Shift: Days - 8-hour shift
• Job Location: Hyde Park (Chicago, IL)
• Unit/Department: Medical Records
• CBA Code: Non-Union

About Us

We've been at the forefront of medicine since 1899. We provide superior healthcare with compassion, always mindful that each patient is a person, an individual. To accomplish this, we need employees with passion, talent and commitment... with patients and with each other. We're in this together: working to advance medical innovation, serve the health needs of the community, and move our collective knowledge forward. If you'd like to add enriching human life to your profile, UChicago Medicine is for you. Here at the forefront, we're doing work that really matters. Join us. Bring your passion.

UChicago Medicine is growing; discover how you can be a part of this pursuit of excellence at: UChicago Medicine Career Opportunities

UChicago Medicine is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, ethnicity, ancestry, sex, sexual orientation, gender identity, marital status, civil union status, parental status, religion, national origin, age, disability, veteran status and other legally protected characteristics.

As a condition of employment, all employees are required to complete a pre-employment physical, background check, drug screening, and comply with the flu vaccination requirements prior to hire. Medical and religious exemptions will be considered for flu vaccination consistent with applicable law.

Compensation & Benefits Overview

UChicago Medicine is committed to transparency in compensation and benefits. The pay range provided reflects the anticipated wage or salary reasonably expected to be offered for the position.

The pay range is based on a full-time equivalent (1.0 FTE) and is reflective of current market data, reviewed on an annual basis. Compensation offered at the time of hire will vary based on candidate qualifications and experience and organizational considerations, such as internal equity. Pay ranges for employees subject to Collective Bargaining Agreements are negotiated by the medical center and their respective union.

Review the full complement of benefit options for eligible roles at Benefits - UChicago Medicine.