Clinical Documentation Specialist - Compliance & Care

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

Job summary

Resurrection Medical Center in Chicago seeks a Clinical Documentation Specialist to perform concurrent and retrospective reviews of inpatient records, ensuring documentation reflects care quality and reimbursement compliance. You will collaborate with physicians and staff to optimize patient documentation and admission criteria.

The role requires clinical background (PA, nursing or medical graduate) with strong communication, critical thinking, and independence in a fast-paced acute care

Qualifications

• Medical Graduate, PA or Nursing Graduate required.
• Minimum of three 1+ year’s clinical experience in an acute care setting.
• Knowledge of care delivery documentation systems and related medical record documents.
• Knowledge of age-specific needs and the elements of disease processes and related procedures.
• Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
• Excellent written and verbal communication skills and critical thinking skills.
• Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, and hospital management staff.
• Working knowledge of inpatient admission criteria.
• Ability to work independently in a time-oriented environment.
• Computer literacy and familiarity with basic office equipment.
• Assertive personality traits to facilitate ongoing physician communication.
• ECFMG Certificate or RN license preferred.
• Prior Case Management Experience preferred.
• Working knowledge of the Medicare reimbursement system and coding structures preferred.
• Current BCLS (AHA) certificate upon hire and maintain current preferred.
• ACLS Certificate preferred.

Responsibilities

• Conduct clinically based concurrent and retrospective reviews of inpatient medical records.
• Evaluate whether clinical documentation reflects quality-of-care outcomes and reimbursement compliance for acute care services.
• Work with medical staff to facilitate appropriate clinical documentation of patient care.
• Document findings for inpatient admission criteria, initial and extended-stay concurrent reviews.

Skills

Clinical documentation

Written & verbal communication

Critical thinking

Interpersonal skills

Time management

Independent worker

Education

Medical Graduate, PA or Nursing Graduate

3+ years clinical experience in acute care

Care delivery documentation systems knowledge

Age-specific needs & disease processes knowledge

Broad clinical knowledge & pathology/physiology

Excellent written and verbal communication

Interpersonal skills to build physician relationships

Inpatient admission criteria knowledge

Ability to work independently in time-oriented environment

Computer literacy & basic office equipment

Assertive communication with physicians

ECFMG certificate or RN license preferred

Prior Case Management experience preferred

Medicare reimbursement knowledge & coding structures

BCLS certificate preferred

ACLS certificate preferred

Job description

Resurrection Medical Center in Chicago seeks a Clinical Documentation Specialist to perform concurrent and retrospective reviews of inpatient records, ensuring documentation reflects care quality and reimbursement compliance. You will collaborate with physicians and staff to optimize patient documentation and admission criteria.

The role requires clinical background (PA, nursing or medical graduate) with strong communication, critical thinking, and independence in a fast-paced acute care