Clinical Documentation Improvement Specialist

Advocate Health Care; Oak Lawn (IL); On-site; USD 85,000 - 110,000; Full time

Job summary

Advocate Health Care is seeking a Clinical Documentation Improvement Nurse to enhance the quality and completeness of patient records through chart reviews, collaboration with physicians and coding staff, and ongoing education. The role emphasizes compliance with regulatory requirements and DRG accuracy.

Ideal candidates hold an Illinois RN license, a BSN, and at least five years of relevant clinical experience with CDI experience preferred.

Qualifications

• Graduate from an accredited school of nursing.
• Current nursing license in the State of Illinois.
• BSN degree required.
• Certification in clinical documentation improvement preferred.
• 5 years relevant clinical experience.

Responsibilities

• Implements improvements to clinical documentation by chart reviews using standards and guidelines.
• Communicates with healthcare team to ensure accurate documentation in medical records.
• Performs follow-up reviews to confirm clarifications and recorded documentation.
• Identifies principal diagnosis and complications to reflect acuity and mortality risk.
• Collaborates with coding staff to assign working DRG and follows up with physicians as needed.
• Provides daily clinical evaluation of the medical record, including labs, diagnostics, and treatment plans.
• Educates internal customers on documentation opportunities, coding, and reimbursement issues.
• Maintains performance measures data and participates in improvement initiatives.
• Supports CDI leadership with development and reporting of metrics.

Skills

Prioritization

Communication

Problem solving

Critical thinking

Computer skills

Interpersonal skills

Education

BSN

RN license

Job description

Advocate Health Care is seeking a Clinical Documentation Improvement Nurse to enhance the quality and completeness of patient records through chart reviews, collaboration with physicians and coding staff, and ongoing education. The role emphasizes compliance with regulatory requirements and DRG accuracy.

Ideal candidates hold an Illinois RN license, a BSN, and at least five years of relevant clinical experience with CDI experience preferred.