Clinical Documentation Spec(Rn)- Full Time Days

Advocate Health Care; Oak Lawn (IL); Hybrid; USD 75,000 - 95,000; Full time

Job summary

Advocate Health Care is seeking a Clinical Documentation Specialist to support hospital and home-based documentation efforts. The role combines on-site and remote work, focusing on improving documentation accuracy for inpatient populations through chart reviews and collaboration with physicians and the health care team.

The ideal candidate holds a BSN with at least 5 years of acute care experience, is licensed in Illinois, and has strong analytical and communication skills to educate staff on

Qualifications

• BSN required with minimum 5 years of inpatient acute care experience (ICU/ED).
• Critical thinking and communication skills essential.
• Ability to prioritize work and handle multiple requests under pressure.
• Certification in clinical documentation improvement preferred.

Responsibilities

• Improve documentation quality and completeness via chart reviews and guidelines.
• Educate internal stakeholders on clinical documentation best practices.
• Collaborate with physicians and care team to ensure accurate severity and risk of mortality capture.

Skills

Critical thinking

Communication skills

Prioritize workload

ICD-10/DRGs knowledge

Education

BSN

Licensed in Illinois

Job description

CLINICAL DOCUMENTATON SPECIALIST

THIS POSITION IS HYBRID, 2 DAYS REMOTE AND 3 DAYS ON SITE

SHIFT:FULL TIME DAYS

This position works both in the hospital and work from home Position Requirements:

• Graduate from an accredited school of nursing BSN minimum 5 years relevant inpatient acute care experience, Critical Care, ICU, ED experience.
• Clinical Documentation Improvement Experience Preferred.
• Ability to prioritize work Excellent communication skills.
• Good problem solving skills Critical thinking skills
• Basic Computer skills
• Effective problem~solver with good interpersonal communication skills verbal and written
• Effective observation analytical and critical thinking skills
• Current nursing license in the State of Illinois
• Certification in clinical documentation improvement preferred.
• Ability to work in 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
• This position needs to recognize needs and behaviors of specific age groups of patients treated.
• Extensive knowledge and experience of ICD~10 coding classification system and DRGs none

Purpose

This role will facilitate the modifications of clinical documentation through extensive initial and concurrent interaction with physicians and other members of the healthcare team to support appropriate documentation of the clinical severity and risk of mortality is captured for the level of services rendered to select inpatients populations. This role will supports timely accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes and provides education to all members of the health care team on an ongoing basis

Accountabilities

Improves the overall quality and completeness of clinical documentation by performing chart reviews using clinical documentation guidelines based on accepted standards evidenced based practice and current regulatory requirements.

Educates all internal customers on clinical documentation opp