Clinical Documentation Specialist RN

Advocate Health Care; Park Ridge (IL); Sur place; USD 90 000 - 120 000; Plein temps

Résumé du poste

Advocate Health Care in Park Ridge, IL is seeking a Registered Nurse with clinical documentation improvement experience to lead chart reviews and ensure compliant, accurate medical records. The role emphasizes precise ICD-10 coding, DRG determination, and collaboration with physicians and coders to reflect patient acuity and outcomes.

You will educate staff on documentation opportunities, participate in performance improvement initiatives, and stay current with coding standards and regulatory

Qualifications

• Graduate from an accredited school of nursing.
• BSN.
• Illinois RN license required.
• Clinical documentation improvement experience preferred.

Responsabilités

• Improve quality and completeness of clinical documentation through chart reviews.
• Communicate with healthcare team to ensure accurate documentation in the medical record.
• Conduct follow-up reviews to ensure clarifications are recorded in the chart.
• Identify principal diagnosis and complications reflecting acuity and mortality per regulations.
• Review coding with staff to assign a working DRG; follow up with physicians as needed.
• Provide daily clinical evaluation of the medical record, including labs and treatment plan.
• Consult with physicians to clarify missing or conflicting documentation.
• Maintain hospital documentation policies and participate in improvement initiatives.
• Gather and analyze information related to documentation findings and outcomes.

Connaissances

Clinical documentation

Nursing

ICD-10 coding

DRG concepts

Communication skills

Critical thinking

Problem solving

Education training

Formation

BSN

Graduate from accredited school of nursing

Illinois RN license

Description du poste

Major Responsibilities

Improves the overall quality and completeness of clinical documentation by performing chart reviews using clinical documentation guidelines based on accepted standards, evidenced based practice, and current regulatory requirements.

• Communicates with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record
• Conducts follow‑up reviews of clinical documentation to ensure points of clarification and agreed upon documentation have been recorded in the patient’s chart.
• Identifies the most appropriate principal diagnosis and complications including date to accurately reflect clinical acuity and risk of mortality in compliance with government regulations
• Reviews clinical issues with coding staff to assign a working DRG, follows up with physicians if appropriate.
• Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plan
• Confers with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness
• Responsible for the day‑to‑day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital’s designated clinical documentation policies and procedures
• Gather and analyze information pertinent to documentation findings and outcomes

Major Responsibilities

Improves the overall quality and completeness of clinical documentation by performing chart reviews using clinical documentation guidelines based on accepted standards, evidenced based practice, and current regulatory requirements.

• Communicates with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record
• Conducts follow‑up reviews of clinical documentation to ensure points of clarification and agreed upon documentation have been recorded in the patient’s chart.
• Identifies the most appropriate principal diagnosis and complications including date to accurately reflect clinical acuity and risk of mortality in compliance with government regulations
• Reviews clinical issues with coding staff to assign a working DRG, follows up with physicians if appropriate.
• Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plan
• Confers with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness
• Responsible for the day‑to‑day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital’s designated clinical documentation policies and procedures
• Gather and analyze information pertinent to documentation findings and outcomes

Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement strategies.

• Demonstrates knowledge of DRG payer issues, documentation opportunities, clinical documentation requirements, coding and policies and procedures.
• Develops educational strategies for physicians and other members of the healthcare team regarding identified documentation opportunities to help support clinical acuity and risk of mortality within the medical record and to understand the significance of appropriate documentation
• Coordinates education to all internal customers related to compliance, coding, and clinical documentation issues. Acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG
• Acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG
• Participates in continuous performance improvement and completes all required educational programs for hospital and medical staff
• Maintains knowledge of current standards of care via literature review and participation in educational offerings
• Research literature to identify new methods development and overall documentation enhancement
• Complete required contact hours based on FTE status, within time frame

Maintains the integrity of data bases, tracks and trends response to clinical documentation and measures for performance improvement.

• Assist site CDI leader in the development and reporting of performance measures to the medical staff and other departments and prepare physician specific data information, as appropriate.
• Completes documentation on reviewed cases in the database.
• Completes the DRG and query indicators for each reviewed case, as appropriate.
• Promotes patient safety by reporting of issues through established channels and participating as requested in safety initiatives.
• Identify patterns, trends variances and opportunities to improve documentation review and process

Demonstrate positive and effective interpersonal relations dealing with all members of the team (ie co‑workers, physicians, leadership, etc.).

• Maintains a positive attitude about assignments and team members
• Promotes professional/personal growth of co‑workers by sharing knowledge and resources.
• Manages stress and personal feelings without a negative impact on the team
• Communicates in a positive and productive manner.
• Demonstrates flexibility with changing workload/assignments.

Licensure: Nurse, Registered (RN) Education/Experience Required

Graduate from an accredited school of nursing

BSN

5 years relevant clinical experience (For associates in process level 25013, 5 years relevant pediatric clinical experience)

Clinical documentation improvement experience preferred

• Knowledge, Skills & Abilities Required: Ability to prioritize work
• Excellent communication skills
• Good problem solving skills
• Critical thinking skills
• Basic Computer skills
• Effective problem‑solver with good interpersonal communication skills, verbal and written
• Effective observation, analytical, and critical thinking skills
• Current nursing license in the State of Illinois.
• Certification in clinical documentation improvement preferred.

Physical Requirements And Working Conditions

• Ability to work in changing environment
• Ability to prioritize independently and respond to multiple simultaneous requests
• Ability to work under stressful conditions and in difficult situations
• May be exposed to hazardous materials and life threatening diseases
• This position needs to recognize needs and behaviors of specific age groups of patients treated.

Extensive knowledge and experience of ICD-10 coding classification system and DRGs none This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.