Clinical Documentation Specialist

Prime Healthcare; Olympia Fields (IL); On-site; USD 39,000 - 59,000; Full time

Benefits offered by this job

401K retirement plan

Medical, dental, vision coverage

Tuition reimbursement

Job summary

Olympia Fields Hospital seeks a Clinical Documentation Specialist to review inpatient records, ensuring documentation accurately reflects patient care and reimbursement requirements. The role involves concurrent and retrospective analyses, collaboration with physicians and hospital staff, and adherence to admission criteria.

Ideal candidates have medical, PA, or nursing backgrounds, with 3+ years in acute care.

Qualifications

• Medical graduate or PA or nursing graduate required.
• Experience in acute care setting (3+ years).
• Knowledge of documentation and coding concepts.
• Familiar with inpatient admission criteria and Medicare rules.
• Excellent written and verbal communication and critical thinking.

Responsibilities

• Conduct concurrent and retrospective reviews of inpatient records to assess documentation quality and reimbursement.
• Collaborate with medical staff to ensure documentation reflects care delivered.
• Evaluate admission criteria and documentation for accuracy during reviews.
• Perform other duties as assigned.

Skills

Clinical knowledge

Communication skills

Critical thinking

Interpersonal skills

Independent work

Computer literacy

Education

Medical graduate/PA/nursing grad

ECFMG or RN preferred

ACLS preferred

Tools

EMR/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

1. Medical Graduate, PA or Nursing Graduate required

2. Minimum of three one (1+) year’s clinical experience in an acute care setting

3. Knowledge of care delivery documentation systems and related medical record documents

4. Knowledge of age-specific needs and the elements of disease processes and related procedures

5. Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.

6. Excellent written, and verbal communication skills and critical thinking skills.

7. Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, and hospital management staff.

8. Working knowledge of inpatient admission criteria.

9. Ability to work independently in a time-oriented environment.

10. Computer literacy and familiarity with the operation of basic office equipment.

11. Assertive personality traits to facilitate ongoing physician communication.

12. ECFMG Certificate or RN license preferred.

13. Prior Case Management Experience preferred.

14. Working knowledge of the Medicare reimbursement system and coding structures preferred.

15. Current BCLS (AHA) certificate upon hire and maintain current preferred.

16. ACLS Certificate preferred.

Pay Transparency

Olympia Fields 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