Clinical Documentation Specialist RN

125 Advocate Health and Hospitals Corporation; Park Ridge (IL); On-site; USD 53,000 - 79,000; Full time

Benefits offered by this job

Health benefits

Paid time off

Education assistance

Job summary

Advocate Lutheran General Hospital in Illinois seeks a Registered Nurse with a BSN and 5+ years of hospital nursing experience to lead clinical documentation improvement efforts. The role emphasizes chart reviews, collaboration with physicians, and ensuring accurate medical records with proper DRG coding.

On-site requirement is three days per week. Experience in ICD-10 coding and a strong grasp of regulatory standards are essential, with a focus on patient safety and quality metrics within a

Qualifications

• BSN required with 5+ years of hospital nursing experience.
• Experience in clinical documentation improvement preferred.
• Illinois RN license required.

Responsibilities

• Improve clinical documentation quality through chart reviews using guidelines and regulatory requirements.
• Communicate with health care team to ensure accurate documentation in the medical record.
• Conduct follow-up reviews to clarify and capture required documentation in the chart.
• Identify principal diagnosis and DRG-related details to reflect acuity and mortality risk.
• Collaborate with physicians and coders to assign correct DRG and improve documentation processes.

Skills

Registered Nurse

BSN

Clinical documentation

Hospital nursing

Communication

Education

BSN

Tools

ICD-10 coding

Job description

Department: 11206 Advocate Lutheran General Hospital - Clinical Document Management Program

Status: Full time

Benefits Eligible: Yes

Hours Per Week: 40

Schedule Details/Additional Information: Candidate must have hospital nursing experience in adult medical / surgical patient population. ICU or PACU experience preferred. Minimum 5 years nursing experience with BSN. Will not accept applicants with only obstetrics, NICU, or psych nursing background. Strong clinical skills are necessary to be successful in this role. Position will require in-person work with physicians and other allied health professionals. On-site work requirement of 3 days per week

Pay Range: $38.20 - $57.30

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.


• 4)Communicates with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record


• 5)Conducts follow-up reviews of clinical documentation to ensure points of clarification and agreed upon documentation have been recorded in the patient’s chart.


• 6)Identifies the most appropriate principal diagnosis and complications including date to accurately reflect clinical acuity and risk of mortality in compliance with government regulations


• 7)Reviews clinical issues with coding staff to assign a working DRG, follows up with physicians if appropriate.


• 2)Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plan


• 3)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


• 1)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


• 8)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.


• 1)Demonstrates knowledge of DRG payer issues, documentation opportunities, clinical documentation requirements, coding and policies and procedures.


• 2)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


• 3)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.


• 5)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.


• 1)Completes documentation on reviewed cases in the database.


• 2)Completes the DRG and query indicators for each reviewed case, as appropriate.


• 3)Promotes patient safety by reporting of issues through established channels and participating as requested in safety initiatives.


• 4)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.).


• 1)Maintains a positive attitude about assignments and team members


• 2)Promotes professional/personal growth of co-workers by sharing knowledge and resources.


• 3)Manages stress and personal feelings without a negative impact on the team


• 4)Communicates in a positive and productive manner.


• 5)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.

Our Commitment to You

• Compensation Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training


• Premium pay such as shift, on call, and more based on a teammate's job


• Incentive pay for select positions


• Opportunity for annual increases based on performance


• Benefits and more Paid Time Off programs


• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability


• Flexible Spending Accounts for eligible health care and dependent care expenses


• Family benefits such as adoption assistance and paid parental leave


• Defined contribution retirement plans with employer match and other financial wellness programs


• Educational Assistance Program Note: Eligibility for programs listed above may depend on your FTE or status (e.g., full-time, part-time, per diem, temporary, etc.); please ask a Recruiter for more information during an interview.

About Advocate Health

Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits. This is Transformation One shared purpose brought us together. Now, as one of the 10 largest not-for-profit, integrated health systems in the United States, our combined strength and stability drives us forward. Starting with You Caring for nearly 3 million people has inspired a transformation. One in which the patient’s experience guides our vision and empowers us to offer new possibilities in our communities.

Reshaping Access

What is access? It’s offering more sites of care than any other health system in the Midwest. But there’s a new frontier. Access is exploring the latest technologies to deliver care to patients exactly where they are and exactly when they need it

Inspiring Professionals

With our dynamically inclusive workforce and strong connections to the places where we live and work, we’ll touch more lives and contribute to stronger and more vibrant communities.

Transforming Care

We’re redefining the standard for care with world-class doctors and caregivers, innovative solutions, outstanding outcomes, and leading-edge research and clinical trials. Combined, Advocate and Aurora are recognized for clinical excellence in: Cardiovascular Care Neurosciences Gynecology Oncology Pediatrics Primary Care Neurology Geriatrics Trauma Care