Inpatient CDS — Documentation & Compliance Expert

Saint Mary of Nazareth Hospital; Chicago (IL); On-site; USD 39,000 - 60,000; Full time

Job summary

Saint Mary of Nazareth Hospital is seeking a Clinical Documentation Specialist to perform concurrent and retrospective reviews of inpatient records, ensuring documentation aligns with care quality and reimbursement standards.

The role requires medical graduate education (PA, nursing, or equivalent) and substantial acute care experience, with strong communication and collaboration skills. Day shifts, full-time, on-site in Chicago.

Qualifications

• Medical graduate with clinical training in acute care settings.

Responsibilities

• Conduct clinically based concurrent and retrospective reviews of inpatient medical records to evaluate documentation reflects quality-of-care outcomes and reimbursement compliance.
• Collaborate with medical staff to facilitate appropriate clinical documentation of patient care.
• Document findings on inpatient admission criteria and initial/extended-stay reviews.
• Perform other duties as assigned or required.

Skills

Written communication

Verbal communication

Critical thinking

Interpersonal skills

Independent work

Time management

Computer literacy

Assertive communication

Physician collaboration

Documentation comprehension

Education

Medical Graduate

PA or Nursing Graduate

ECFMG/RN license preferred

ACLS certificate preferred

BCLS certificate preferred

Tools

Care delivery documentation systems

Job description

Saint Mary of Nazareth Hospital is seeking a Clinical Documentation Specialist to perform concurrent and retrospective reviews of inpatient records, ensuring documentation aligns with care quality and reimbursement standards.

The role requires medical graduate education (PA, nursing, or equivalent) and substantial acute care experience, with strong communication and collaboration skills. Day shifts, full-time, on-site in Chicago.