Clinical Documentation Specialist, Lead

NorthShore University HealthSystem; Naperville (IL); On-site; USD 99,000 - 154,000; Full time

Benefits offered by this job

Annual increases

Tuition Reimbursement

Paid Time Off

Retirement options with company match

Free Parking

Job summary

NorthShore University HealthSystem seeks a Lead Clinical Documentation Integrity (CDI) Specialist in Naperville, IL, to guide the CDI program and mentor staff. This full-time role emphasizes second-level reviews, education, and collaboration with physicians to improve documentation quality and reduce denials.

The Lead will oversee day-to-day CDI operations, review complex cases, and support performance improvements across the organization. Travel may be required for trainings.

Qualifications

• Associates Degree in Nursing or Health Information Management; Bachelors preferred.
• RN license required; RHIT/RHIA or CCS preferred.
• 3+ years inpatient CDI experience; 3+ years RN in acute care.
• Strong clinical knowledge and communication skills.

Responsibilities

• Perform medical record reviews to ensure accuracy and completeness.
• Clarify missing or conflicting documentation via queries.
• Collaborate with providers to document diagnoses and treatments.
• Develop and manage CDI queries compliant with AHIMA/ACDIS.
• Mentor staff on advanced CDI topics and provide education.
• Assist with denials/appeals and contribute to process improvements.

Skills

CDI Leadership

Medical Record Review

Query Management

Education & Mentoring

Education

Associate Degree in Nursing

RN License

RHIT or RHIA preferred

Tools

AHIMA Guidelines

Job description

Hourly Pay Range:

$47.72 - $73.97 - The hourly pay rate offered is determined by a candidate's expertise and years of experience, among other factors.

Clinical Documentation Specialist, Lead

The Lead Clinical Documentation Integrity (CDI) Specialist reports to the Director of Clinical Documentation, the Lead Clinical Documentation Specialist provides second level reviews for identified cases, provides complex chart reviews, and uses advanced CDI and coding knowledge to drive performance, identify opportunity, improve quality outcome measures and prevent denials. The Lead Clinical Documentation Specialist will have a role in providing education, including orientation and mentoring of new employees. The Lead may be asked to assist with cases on escalation and with denials/appeal letters. The Lead will facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation. The Lead serves as a resource and mentor to all members of the health care team for coding and documentation guidelines.

Position Highlights:

• Position: Clinical Documentation Specialist, Lead
• Location: Edward Hospital (Naperville, IL)
• Full Time/Part Time: Full Time (40 hours)
• Hours: Monday-Friday, 8:00am-4:30pm
• Required Travel: travel to other Endeavor Health locations may be required for trainings and meetings

What you will do:

Medical Record Reviews/Day to Day Operations

• Review medical records concurrently to ensure accuracy, completeness, and specificity of clinical documentation.
• Identify and clarify missing, conflicting, or nonspecific physicians' documentation through queries and follow up.
• Collaborate with healthcare providers to ensure accurate and comprehensive documentation of patient diagnoses and treatments.
• Monitors and assists with team case assignments to ensure accurate case coverage per organizational needs.
• Identifies and provides feedback to the Director on optimization of workflow processes. Takes a case assignment as deemed necessary by the CDI Director during times of high census, PTO or short staffing.

Query Management and Compliance

• Develop and implement effective queries to resolve documentation issues.
• Ensure queries are clear, concise, and compliant with industry's standards and regulatory requirements.
• Track and follow up on outstanding queries to ensure timely responses.
• Query format and questions meet AHIMA and ACIDS guideline.
• Ensures adherence to professional standards, quality standards, licensure, and federal laws.

Quality

• Ensure clinical documentation complies with all applicable regulations and standards, including those set by CMS, Joint Commission, and other governing bodies.
• Performs complex chart reviews for advanced CDI topics and serves as a mentor to staff on such cases. May include DRG pre-billing opportunity reviews, or to identify/resolve denials risk.

Physician Collaboration and Education

• Provide education to the physicians and other clinical staff on documentation best practice and importance of accurate clinical documentation.

Professional Development

• Attend education programs, workshops, and one-one-one training to enhance continuous learning.
• Participate in professional organization such as the Clinical Documentation Improvement Specialist (ACDIS) or the American Health Information Management. Actively engage in mentoring relationships to support less experienced colleagues and contribute to professional development within the team.

Other Duties as Assigned

• May include but not limited to special projects related to Revenue Cycle, process improvement, task forces or Endeavor Health System workflows.

What you will need:

• Education: Associates Degree in Nursing or Health Information Management, required. Bachelors Degree in Nursing, preferred.
• Certification:
  • RHIT or RHIA through AHIMA, preferred
  • RN License through IDFPR, required
  • Certified Clinical Documentation Specialist, preferred
  • Certified Coding Specialist, preferred
• Experience:
  • 3+ years recent inpatient clinical documentation specialist experience, required
  • 3+ years RN experience within an Acute Care Hospital (critical care preferred)
  • 3+ years HIM with CDI experience
• Unique or Preferred Skills:
  • Strong clinical knowledge and demonstrated commitment to maintaining relevancy in the clinical field.
  • The communication skills to deliver presentations involving complex issues to a wide audience.
  • Excellent analytical and communication skills.
  • Ability to work independently and collaboratively in a team environment.

Benefits (For full time or part time positions):

• Opportunity for annual increases based on performance
• Career Pathways to Promote Professional Growth and Development
• Various Medical, Dental, Pet and Vision options
• Tuition Reimbursement
• Free Parking
• Wellness Program Savings Plan
• Health Savings Account Options
• Retirement Options with Company Match
• Paid Time Off and Holiday Pay
• Community Involvement Opportunities

Endeavor Health is a fully integrated healthcare delivery system committed to providing access to quality, vibrant, community-connected care, serving an area of more than 4.2 million residents across six northeast Illinois counties. Our more than 25,000 team members and more than 6,000 physicians aim to deliver transformative patient experiences and expert care close to home across more than 300 ambulatory locations and eight acute care hospitals - Edward (Naperville), Elmhurst, Evanston, Glenbrook (Glenview), Highland Park, Northwest Community (Arlington Heights) Skokie and Swedish (Chicago) - all recognized as Magnet hospitals for nursing excellence. For more information, visit www.endeavorhealth.org.

When you work for Endeavor Health, you will be part of an organization that encourages its employees to achieve career goals and maximize their professional potential.

Please explore our website www.endeavorhealth.org to better understand how Endeavor Health delivers on its mission to "help everyone in our communities be their best".

Endeavor Health is committed to working with and providing reasonable accommodation to individuals with disabilities. Please refer to the main career page for more information.

At Endeavor Health, we are united by a shared commitment to working together to create a culture of connection and belonging-each of us bringing different skills and experiences as we deliver safe, seamless, and personal care. Every person, every time. We are committed to fostering an environment where all team members can be their best, learn, and pursue excellence together.

EOE: Race/Color/Sex/Sexual Orientation/ Gender Identity/Religion/National Origin/Disability/Vets, VEVRRA Federal Contractor.