Clinical Documentation Specialist RN

About the role

The role is a full-time position with benefits eligibility. It is a hybrid position requiring 3 days on-site and 2 days remote.

Responsibilities

• Improves clinical documentation quality and completeness
• Communicates with healthcare team members to ensure accurate documentation
• Follows up on clinical documentation to ensure clarity and completeness
• Assigns appropriate principal diagnoses and complications
• Reviews clinical issues with coding staff to assign DRGs
• Evaluates medical records for completeness and accuracy
• Confers with physicians to clarify and document medical record information
• Educates internal customers on clinical documentation, coding, and reimbursement issues
• Develops educational strategies for improving clinical documentation
• Coordinates education on compliance, coding, and documentation issues
• Consults with coders on documentation issues
• Maintains knowledge of current standards of care
• Tracks and measures performance improvement
• Promotes patient safety by reporting issues and participating in safety initiatives
• Identifies patterns and trends in documentation
• Supports the Medical Staff with performance measures
• Completes documentation and DRG queries
• Manages stress and maintains a positive attitude
• Communicates effectively with all team members

Requirements

• Nurse, Registered (RN)
• Bachelor of Science in Nursing (BSN)
• 5 years relevant clinical experience (or 5 years relevant pediatric clinical experience for Associates in process level 25013)
• Clinical documentation improvement experience preferred
• Current nursing license in the State of Illinois
• Certification in clinical documentation improvement preferred

Qualifications

• Ability to prioritize work
• Excellent communication skills
• Good problem-solving skills
• Critical thinking skills
• Basic computer skills
• Effective problem-solver with good interpersonal communication skills
• Effective observation, analytical, and critical thinking skills

Skills

• Knowledge of ICD-10 coding classification system and DRGs

Benefits

Comprehensive suite of Total Rewards including compensation, benefits, and educational assistance programs. Eligibility for benefits depends on FTE status.

Pay

$38.20 - $57.30 per hour

Schedule

Hybrid position, 3 days on-site, 2 days remote