Clinical Documentation Specialist
UChicago Medicine · Chicago, IL · 3 wk ago
HybridFinanceFull-time
About the role
This position is hybrid and requires travel to our Hyde Park Campus in Chicago, IL as needed.
Responsibilities
- Facilitate improvement in the overall quality and completeness of medical record documentation on a concurrent basis.
- Promote 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.
- Obtain appropriate clinical documentation through collaborative communications with physicians, nursing staff, other patient care providers, and the Health Information Management Department Coders.
- Provide informal and formal education to all members of the care team regarding clinical documentation.
- Communicate 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.
- Demonstrate and apply basic knowledge of documentation requirements and guidelines in accordance with ICD-10 CM Official Guidelines for Coding and Reporting.
- Maintain the confidentiality of information acquired pertaining to patients, physicians, associates, and visitors.
- Assume 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.
Requirements
- 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.
Qualifications
- 5-8 years’ experience in Case Management or Med/Surg or Critical Care nursing experience.
- Master's Degree.
- CSSC coding credential.
Skills
- Strong analytical and communication skills.
- Knowledge of ICD-10 CM Official Guidelines for Coding and Reporting.
- Ability to maintain confidentiality.
- Effective interpersonal and educational skills.
Benefits
Details about benefits will be provided upon request.
Pay
Details about pay will be provided upon request.
Schedule
Details about schedule will be provided upon request.