Clinical Documentation Specialist

University of Chicago Medical Center; Indiana; Remote; USD 70,000 - 90,000; Full time

Job summary

Join a world-class academic healthcare system as a Clinical Documentation Specialist at UChicago Medicine. This remote role involves enhancing the quality of medical record documentation and collaborating with clinical staff to ensure accuracy and completeness. The position requires a Bachelor's degree in Nursing and an active RN license, with preferred experience in Case Management or Critical Care Nursing.

Qualifications

• Active Registered Nurse license required.
• 5-8 years of experience in Case Management, Med/Surg, or Critical Care Nursing preferred.
• CCS coding credential preferred.

Responsibilities

• Facilitates improvement in medical record documentation quality.
• Collaborates with healthcare providers for accurate clinical service representation.
• Provides education to the care team regarding documentation.

Skills

Interpersonal skills

Analytic skills

Prioritization skills

Organizational skills

Education

Bachelor's degree in Nursing

Master's degree in Nursing

Tools

ICD-9 CM Official Guidelines

Job description

Job Description

Be a part of a world-class academic healthcare system, UChicago Medicine, Advent Health as a Clinical Documentation Specialist.This is a remote, work from home opportunity and you may be based outside of the greater Chicagoland area.

The Clinical Document Specialist (CDS) is responsible for facilitating improvement in the overall quality and completeness of medical record documentation on a concurrent basis. The CDS promotes modifications to medical record documentation to ensure accurate depiction of the level of clinical services provided to the patient and to completely describe patients’ severity of illness. The CDS obtains appropriate clinical documentation through collaborative communications from having developed positive working relationships with physicians, nursing staff, other patient care providers, and the Health Information Management Department Coders. The CDS is also responsible for providing informal and formal education to all members of the care team regarding clinical documentation.

Essential Job Functions

• Reviews and re-reviews inpatient medical records for identified payer populations (primarily DRG/Case Rate payment methodology ) beginning approximately 48 after admission. Analyzes the medical record regarding the clinical status of patient, current treatment plan and past medical history and seeks clarification of incomplete, unclear, and ambiguous clinical documentation
• Communicates with attending physician(s) verbally and through written methodology to validate observations, and obtain clarification of incomplete, unclear, and ambiguous documentation including clarification of POA
• Demonstrates and applies basic knowledge of documentation requirements and guidelines in accordance with ICD-9 CM Official Guidelines for Coding and Reporting.
• Works closely with HIM coding staff to assure documentation of principal diagnosis and any co-existing comorbidities and complications accurately reflect the patient’s clinical status and level of services provided. Reviews attestation of all billed diagnoses and procedures and reports discrepancies to HIM coding staff
• Consistently meets established productivity targets for record review
• Develops and implements plans for both formal and informal education of physician, nursing and other clinical staff
• Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation
• Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of co-workers, and to report all preventable hazards and unsafe practices immediately to management
• Performs other duties as requested by senior management

Required Qualifications:

• 5 -8 years progressive work experience: Case Management or Med/Surg or Critical Care Nursing experience preferred.
• Basic computer skills in word processing and spreadsheet utilization
• Excellent interpersonal skills necessary to develop and foster effective physician communication
• Analytic skills necessary to clinically assess medical records
• Excellent prioritization and organizational skills
• Must be an actively licensed Registered Nurse
• A Bachelor's degree in Nursing
• ILLINOIS LICENSURE IS REQUIRED

Preferred Qualifications:

• Master's degree in Nursing
• CCS coding credential

Position Details:

• Job Type/FTE:Full-Time 1.0 FTE
• Shift: Days
• Work Location: REMOTE
• Unit/Department: Center for Transformative Care
• CBA Code: Non-Union

Why Join Us

We’ve been at the forefront of medicine since 1899. We provide superior healthcare with compassion, always mindful that each patient is a person, an individual. To accomplish this, we need employees with passion, talent and commitment… with patients and with each other. We’re in this together: working to advance medical innovation, serve the health needs of the community, and move our collective knowledge forward. If you’d like to add enriching human life to your profile, UChicago Medicine is for you. Here at the forefront, we’re doing work that really matters. Join us. Bring your passion.

UChicago Medicine is growing; discover how you can be a part of this pursuit of excellence at:UChicago Medicine Career Opportunities.

UChicago Medicine is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, ethnicity, ancestry, sex, sexual orientation, gender identity, marital status, civil union status, parental status, religion, national origin, age, disability, veteran status and other legally protected characteristics.

Must comply with UChicago Medicine’s COVID-19 Vaccination requirement as a condition of employment. If you have already received the vaccination, you must provide proof as part of the pre-employment process. This is in addition to your compliance with the Flu Vaccination requirement as well. Medical and religious exemptions will be considered consistent with applicable law. Lastly, a pre-employment physical, drug screening, and background check are also required for all employees prior to hire.

Compensation & Benefits Overview

UChicago Medicine is committed to transparency in compensation and benefits. The pay range provided reflects the anticipated wage or salary reasonably expected to be offered for the position.

The pay range is based on a full-time equivalent (1.0 FTE) and is reflective of current market data, reviewed on an annual basis. Compensation offered at the time of hire will vary based on candidate qualifications and experience and organizational considerations, such as internal equity. Pay ranges for employees subject to Collective Bargaining Agreements are negotiated by the medical center and their respective union.

Review the full complement of benefit options for eligible roles at Benefits - UChicago Medicine.