Clinical Documentation Specialist RN

Full-time Clinical Documentation Specialist RN position (40 hours per week) in the Clinical Document Management Program at Advocate Lutheran General Hospital, requiring on-site work three days per week.

Responsibilities

Improve the overall quality and completeness of clinical documentation by performing chart reviews; Communicate with healthcare team members to ensure accurate and complete documentation in the medical record; Conduct follow-up reviews of clinical documentation; Identify the most appropriate principal diagnosis and complications; Review clinical issues with coding staff to assign a working DRG; Provide daily clinical evaluation of the medical record; Confer with physicians regarding missing, unclear or conflicting documentation; Educate internal customers on clinical documentation opportunities, coding and reimbursement issues; Develop educational strategies for physicians and healthcare team members; Coordinate education related to compliance, coding, and clinical documentation; Act as a consultant to coders; Participate in continuous performance improvement; Maintain the integrity of databases and track clinical documentation performance measures; Complete documentation on reviewed cases in the database; Promote patient safety by reporting issues through established channels

Requirements

Hospital nursing experience in adult medical/surgical patient population; Minimum 5 years nursing experience with BSN; Graduate from an accredited school of nursing; 5 years relevant clinical experience; Current nursing license in the State of Illinois; Extensive knowledge and experience of ICD-10 coding classification system and DRGs; Strong clinical skills; Ability to prioritize work; Excellent communication skills; Good problem solving skills; Critical thinking skills; Basic computer skills; Effective observation and analytical skills; Ability to work in a changing environment; Ability to work under stressful conditions

Nice to have

ICU or PACU experience; Clinical documentation improvement experience; Certification in clinical documentation improvement

Benefits

Paid Time Off programs; Health and welfare benefits including medical, dental, vision, life, and Short- and Long-Term Disability; Flexible Spending Accounts; Family benefits such as adoption assistance and paid parental leave; Defined contribution retirement plans with employer match; Financial wellness programs; Educational Assistance Program; Opportunity for annual increases based on performance; Premium pay for select positions; Incentive pay for select positions