Inpatient CDS: Elevate Documentation & Compliance

Saint Francis Hospital; Evanston (IL); On-site; USD 58,000 - 90,000; Full time

Job summary

Saint Francis Hospital is seeking a Clinical Documentation Specialist to perform concurrent and retrospective reviews of inpatient records to ensure documentation aligns with quality-of-care outcomes and reimbursement standards.

You will collaborate with physicians and nursing staff to document care accurately, assess admission criteria, and complete initial and extended-stay reviews. Strong communication and clinical knowledge are essential.

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.
• ECFMG Certificate or RN license preferred.
• ACLS Certificate preferred.
• Current BCLS (AHA) certificate upon hire and maintain current preferred.

Responsibilities

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

Skills

Communication skills

Critical thinking

Interpersonal skills

Independent work

Education

Medical/Nursing graduate

3+ years acute care experience

ECFMG/RN license preferred

ACLS preferred

BCLS preferred

Job description

Saint Francis Hospital is seeking a Clinical Documentation Specialist to perform concurrent and retrospective reviews of inpatient records to ensure documentation aligns with quality-of-care outcomes and reimbursement standards.

You will collaborate with physicians and nursing staff to document care accurately, assess admission criteria, and complete initial and extended-stay reviews. Strong communication and clinical knowledge are essential.