Clinical Documentation Specialist

AdventHealth; United States; Remote; USD 72,000 - 134,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

403(b) retirement plan

PTO from day one

Parental leave

Career development

Mental health resources

Job summary

UChicago Medicine AdventHealth in Illinois seeks a Clinical Documentation Specialist to educate care teams on documentation regulations and collaborate with physicians to ensure complete and accurate clinical records.

The role requires 5+ years of acute care nursing experience; RN/PA/MD/CRNP eligibility is essential, with coding background and quality guideline knowledge preferred. Remote scheduling options and a strong benefits package available.

Qualifications

• RN with 5+ acute care nursing experience required.
• Licensure as RN or equivalent required; physicians/PA/MD acceptable.
• Experience with clinical documentation standards preferred.

Responsibilities

• Educates patient-care team on documentation regulations and guidelines.
• Communicates with physicians to ensure accurate clinical documentation.
• Resolves discrepancies in assignments and coding issues.
• Performs timely reviews of concurrent cases for SOI/ROM quality.
• Participates in department meetings and provides feedback.
• Maintains high physician response rate to clarifications.

Skills

Interpersonal skills

Verbal communication

Written communication

Computer skills

Keyboarding

Multitasking

Critical thinking

Pathophysiology knowledge

Prioritization

Education

Bachelor's in Nursing

Master's in Nursing

Tools

Coding background

Quality guidelines

Job description

Our Promise to You

Joining UChicago Medicine AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. UChicago Medicine AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Benefits from Day One

Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance Paid Time Off from Day One 403-B Retirement Plan 4 Weeks 100% Paid Parental Leave Career Development Whole Person Well-being Resources Mental Health Resources and Support Pet Benefits

Schedule

flexible scheduling, any eight-hour shift between 6am and 6pm Monday-Friday. Full Remote

Location

Address: 5101 WILLOW SPRINGS RD City: LA GRANGE State: Illinois Postal Code: 60525

Job Description

• Educates members of the patient-care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, and nursing staff.
• Communicates effectively with physicians and other healthcare providers to ensure appropriate, accurate, and complete clinical documentation.
• Collaborates with staff to resolve discrepancies with assignments and coding issues.
• Conducts well-timed follow-up case reviews on all concurrent cases, prioritizing those with clinical documentation clarifications.
• Participates in department meetings, providing feedback on outstanding issues and presenting educational opportunities.
• Maintains a 95% physician response rate to all valid clarifications.
• Reviews concurrent medical records for compliance, including completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), and quality.
• Completes accurate and timely record reviews to ensure the integrity of documentation compliance.
• Inputs data accurately into CDI Software, resulting in precise metrics obtained through the reconciliation process.
• Initiates and formulates CDI severity worksheets and clinically credible clarifications for inpatients, presenting opportunities for improved documentation compliance to clinical team members.
• Transcribes documentation clarifications as appropriate to ensure documentation compliance.
• Other duties as assigned.

Knowledge, Skills, and Abilities

• Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrates excellent physician relations. [Required]
• Able to organize and present information clearly and concisely; excellent computer and keyboarding skills; ability to use multiple software programs simultaneously; high degree of prioritization skills. [Required]
• Ability to learn/develop and fine-tune the skills necessary to perform optimally as a Clinical Documentation Specialist. [Required]
• Dependable, self-motivated and pleasant. [Required]
• Utilize and demonstrate excellent critical-thinking, problem-solving and deductive-reasoning skills. [Required]
• Knowledge of pathophysiology, disease processes and treatments. [Required]
• Strong ability to organize/triage work and manage multiple priorities at once. [Required]
• Knowledge of clinical documentation requirements that identify clinical conditions or procedures. [Preferred]
• Coding background. [Preferred]
• Knowledge of quality guidelines. [Preferred]

Education

• Bachelor's of Nursing [Preferred]
• Master's of Nursing [Preferred]

Field of Study

• completed in health service administration, business administration, system performance engineering, industrial engineering, or public health

Work Experience

• 5+ acute care nursing experience with specific medical/surgical, intensive care, post-acute care unit, or emergency department experience. [Required]
• Clinical Documentation Specialist experience [Preferred]

Licenses and Certifications

• Registered Nurse (RN) [Required] OR Physician Assistant (PA) [Required] OR Medical Doctor (MD) [Required] OR Certified Registered Nurse Practitioner (CRNP) [Required] OR Adult Acute Care Nurse Practitioner (ACNPC) [Required] OR Educational Commission for Foreign Medical Graduates (ECFMG) [Required] OR Certified Clinical Documentation Specialist (CCDS) [Preferred] OR Certified Documentation Improvement Practitioner (CDIP) [Preferred]

Physical Requirements

Physical Requirements: (Please click the link below to view work requirements) Physical Requirements - https://tinyurl.com/23km2677

Pay Range

Pay Range: $72,300.80 - $134,472.00

Equal Opportunity Employer

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

Mission Statement

Every day, our fellow team members show up to work, unified by one shared mission: Extending the Healing Ministry of Jesus Christ. As a faith-based health care organization, our story is one of hope as we strive to heal and restore the body, mind and spirit. Though our facilities are spread across the country, this unwavering belief binds us together. Across every office, exam and patient room, we’re committed to providing individualized, holistic care. This is our Christian mission, and it inspires us to help make communities healthier and happier.