Clinical Documentation Specialist-RN - Sherman

Clinical Documentation Specialist - RN (Sherman)

Join to apply for the Clinical Documentation Specialist - RN role at Advocate Health Care
.

This role offers a base pay range of $37.50/hr - $56.25/hr your actual pay will be based on your skills and experience.

• Improves overall quality and completeness of clinical documentation by performing chart reviews using clinical documentation guidelines based on accepted standards, evidence-based practice, and current regulatory requirements.
• Communicates with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record.
• Conducts follow‑up reviews of clinical documentation to ensure points of clarification and agreed‑upon documentation have been recorded in the patient’s chart.
• Identifies the most appropriate principal diagnosis and complications, including dates to accurately reflect clinical acuity and risk of mortality in compliance with government regulations.
• Reviews clinical issues with coding staff to assign a working DRG, and follows up with physicians when appropriate.
• Provides daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information, and treatment plan.
• Confers with physicians, face‑to‑face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify information, obtain needed documentation, present opportunities, and educate on appropriate identification of severity of illness.
• Responsible for day‑to‑day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital’s designated clinical documentation policies and procedures.
• Gathers and analyzes information pertinent to documentation findings and outcomes.

• Graduate from an accredited school of nursing with a BSN.
• 5 years relevant clinical experience (for associates, 5 years relevant pediatric clinical experience).
• Clinical documentation improvement experience preferred.

• Ability to prioritize work.
• Excellent communication skills.
• Good problem‑solving and critical‑thinking skills.
• Basic computer skills.
• Effective observation, analytical, and critical‑thinking skills.
• Certification in clinical documentation improvement preferred.

• Registered Nurse (RN), current nursing license in the State of Illinois.

• Ability to work in a changing environment.
• Ability to prioritize independently and respond to multiple simultaneous requests.
• Ability to work under stressful conditions and in difficult situations.
• May be exposed to hazardous materials and life‑threatening diseases.
• Must have extensive knowledge and experience of ICD‑10 coding classification system and DRGs.
• Must have acute care hospital experience; experience limited to OB, Psych, and Rehab is not considered.
• Position requires recognition of needs and behaviors of specific age groups of patients treated.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive list of activities, duties, or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.