RN CDI Specialist: Elevate Clinical Documentation

Advocate Health Care; Chicago (IL); On-site; USD 75,000 - 110,000; Full time

Job summary

Advocate Health Care seeks an experienced Registered Nurse with a BSN to join our Clinical Documentation Improvement team in Illinois. You will perform chart reviews, ensure accurate and complete documentation, and collaborate with physicians and coders to reflect patient acuity and improve reimbursement compliance.

Responsibilities include daily evaluation of medical records, education of staff, and development of documentation strategies.

Qualifications

• Registered nurse with active Illinois license.
• BSN required.
• Minimum 5 years of relevant clinical experience.
• Clinical documentation improvement experience preferred.
• Ability to prioritize work and multitask in a fast-paced hospital environment.

Responsibilities

• Improves the overall quality and completeness of clinical documentation by performing chart reviews based on clinical documentation guidelines and regulatory requirements.
• Communicates with healthcare team members to ensure accurate documentation in the medical record.
• Conducts follow-up reviews to confirm documentation clarification and recording in the patient chart.
• Identifies principal diagnosis and complications to reflect acuity and mortality risk per regulations.
• Reviews clinical issues with coding staff to assign a working DRG and follows up with physicians as needed.
• Provides daily clinical evaluation of the medical record including documentation, labs, diagnostics, and treatment plan.
• Educates physicians and staff on documentation opportunities and coding requirements to support reimbursement and compliance.
• Maintains data quality, dashboards, and performance measures related to clinical documentation.

Skills

Communication skills

Critical thinking

Interpersonal communication

Problem solving

Basic computer skills

Education

BSN

Accredited nursing program

Tools

EMR systems

Job description

Advocate Health Care seeks an experienced Registered Nurse with a BSN to join our Clinical Documentation Improvement team in Illinois. You will perform chart reviews, ensure accurate and complete documentation, and collaborate with physicians and coders to reflect patient acuity and improve reimbursement compliance.

Responsibilities include daily evaluation of medical records, education of staff, and development of documentation strategies.