CDS

Saint Mary of Nazareth Hospital; Chicago (IL); On-site; USD 39,000 - 60,000; Full time

Job summary

Saint Mary of Nazareth Hospital is seeking a Clinical Documentation Specialist to perform concurrent and retrospective reviews of inpatient records, ensuring documentation aligns with care quality and reimbursement standards.

The role requires medical graduate education (PA, nursing, or equivalent) and substantial acute care experience, with strong communication and collaboration skills. Day shifts, full-time, on-site in Chicago.

Qualifications

• Medical graduate with clinical training in acute care settings.

Responsibilities

• Conduct clinically based concurrent and retrospective reviews of inpatient medical records to evaluate documentation reflects quality-of-care outcomes and reimbursement compliance.
• Collaborate with medical staff to facilitate appropriate clinical documentation of patient care.
• Document findings on inpatient admission criteria and initial/extended-stay reviews.
• Perform other duties as assigned or required.

Skills

Written communication

Verbal communication

Critical thinking

Interpersonal skills

Independent work

Time management

Computer literacy

Assertive communication

Physician collaboration

Documentation comprehension

Education

Medical Graduate

PA or Nursing Graduate

ECFMG/RN license preferred

ACLS certificate preferred

BCLS certificate preferred

Tools

Care delivery documentation systems

Job description

Responsibilities

The Clinical Documentation Specialist (CDS) is responsible for conducting clinically based concurrent and retrospective reviews of inpatient medical records. These reviews are to evaluate whether the clinical documentation is reflective of the quality-of-care outcomes and reimbursement compliance for acute care services provided. The CDS works closely with the medical staff to facilitate appropriate clinical documentation of patient care. Other responsibilities include conducting documentation for inpatient admission criteria, initial and extended-stay concurrent reviews on all selected admissions and documenting findings. He/She will perform other duties as assigned or required.

Qualifications

EDUCATION, EXPERIENCE, TRAINING

• Medical Graduate, PA or Nursing Graduate required
• Minimum of three one (1+) year’s clinical experience in an acute care setting
• Knowledge of care delivery documentation systems and related medical record documents
• Knowledge of age-specific needs and the elements of disease processes and related procedures
• Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
• Excellent written, and verbal communication skills and critical thinking skills.
• Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, and hospital management staff.
• Working knowledge of inpatient admission criteria.
• Ability to work independently in a time-oriented environment.
• Computer literacy and familiarity with the operation of basic office equipment.
• Assertive personality traits to facilitate ongoing physician communication.
• ECFMG Certificate or RN license preferred.
• Prior Case Management Experience preferred.
• Working knowledge of the Medicare reimbursement system and coding structures preferred.
• Current BCLS (AHA) certificate upon hire and maintain current preferred.
• ACLS Certificate preferred.

Pay Transparency

Saint Mary of Nazareth Hospital offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $28.00 to $43.40. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.

The company is dedicated to empowering its staff with a comprehensive, competitive benefits package, allowing them the freedom to customize their benefits to fit their unique needs. Our abundant resources, programs, and voluntary options serve as a foundation for individual growth and well-being. Learn more here: https://www.primehealthcare.com/benefitsthatmattermost/

Employment Status

Full Time

Shift

Days

Equal Employment Opportunity

Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf