RN Clinical Documentation Specialist

Hourly Pay Range: $38.67 - $59.94 – The hourly pay rate offered is determined by a candidate's expertise and years of experience, among other factors.

About the role

This role involves improving the overall quality and completeness of clinical documentation to ensure accurate coding, appropriate reimbursement, and compliance with regulatory requirements. You will work closely with physicians, healthcare providers, and coding staff to clarify and enhance the documentation of clinical information.

Location: Hybrid – Skokie, IL and remote
Full Time (40 hours per week)
Hours: Monday-Friday, 8:00am-4:30pm
Required travel to other Endeavor Health locations for in-person trainings and meetings

Responsibilities

• Review medical records concurrently to ensure accuracy, completeness, and specificity of clinical documentation.
• Identify and clarify missing, conflicting, or nonspecific physicians’ documentation through queries and follow-up.
• Collaborate with healthcare providers to ensure accurate and comprehensive documentation of patient diagnoses and treatments.
• Develop and implement effective queries to resolve documentation issues.
• Ensure queries are clear, concise, and compliant with industry standards and regulatory requirements.
• Track and follow up on outstanding queries to ensure timely responses.
• Ensure query format and questions meet AHIMA and ACDIS guidelines.
• Ensure clinical documentation complies with all applicable regulations and standards, including those set by CMS, Joint Commission, and other governing bodies.
• Provide education to physicians and other clinical staff on documentation best practices and the importance of accurate clinical documentation.
• Attend education programs, workshops, and one-on-one training to enhance continuous learning.
• Participate in professional organizations such as the Association of Clinical Documentation Improvement Specialists (ACDIS) or the American Health Information Management Association (AHIMA).
• Actively engage in mentoring relationships to support less experienced colleagues and contribute to professional development within the team.

Requirements

• Associate degree in Nursing or Health Information Management (HIM) is required; Bachelor’s degree in Nursing is preferred.
• Certification: ADN or RHIT; Illinois Licensed RN preferred.
• 3-5 years of RN experience in an Acute Care Hospital (critical care preferred).

Skills

• Strong clinical knowledge and demonstrated commitment to maintaining relevancy in the clinical field.
• Excellent analytical and communication skills.
• Ability to work independently and collaboratively in a team environment.
• Proficient in using electronic medical record (EMR) and clinical tools.
• Familiarity with healthcare regulations, including HIPAA, and documentation standards.
• Proficient in using office software (e.g., Microsoft Office Suite, Excel) and other communication platforms (e.g., email, video conferencing) for collaboration and reporting.

Benefits

• Opportunity for annual increases based on performance.
• Career pathways to promote professional growth and development.
• Various medical, dental, pet, and vision options.
• Tuition reimbursement.
• Free parking.
• Wellness program savings plan.
• Health Savings Account options.
• Retirement options with company match.
• Paid time off and holiday pay.
• Community involvement opportunities.