Clinical Documentation Specialist (RN)

About the role

Aurora St. Luke’s Medical Center is seeking a detail-oriented, clinically experienced Registered Nurse to join their 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.

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.

Requirements

• Registered Nurse (RN) license issued by the state of Wisconsin in which the team member practices.
• Associate Degree in Nursing (ADN) required.
• Minimum of 2 years of recent clinical nursing experience, preference for candidates with ICU or other high-acuity inpatient experience.
• 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.
• Ability to work independently while partnering effectively with providers and interdisciplinary teams.
• Availability to work on-site two days per week.

Qualifications

• Comfort working in electronic medical records and Microsoft Word.

Skills

• 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.
• Ability to work independently while partnering effectively with providers and interdisciplinary teams.

Benefits

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.

Pay

Negotiable based on experience and qualifications.

Schedule

Hybrid schedule with an expectation to be on-site three days per week.

Location

Aurora St. Luke’s Medical Center, one of Wisconsin’s premier tertiary care and academic medical centers.

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.