RN Clinical Documentation Specialist

Advocate Health Care; Park Ridge (IL); On-site; USD 95,000 - 115,000; Full time

Job summary

Advocate Health Care is seeking a Clinical Documentation Improvement professional (RN) to enhance chart quality and ensure accurate DRG assignments. You will review patient records, collaborate with physicians and coding staff, and provide daily assessments of clinical documentation, labs, and treatment plans.

Strong communication, critical thinking, and CDI experience are required. Graduate from an accredited nursing program with an Illinois RN license (BSN preferred).

Qualifications

• Nursing degree and RN license in Illinois.
• BSN preferred; CDI experience preferred.
• 5 years relevant clinical experience; pediatrics noted for associates in process level 25013.

Responsibilities

• Improve documentation quality via chart reviews using CDI guidelines.
• Communicate with healthcare team to ensure accurate documentation in the medical record.
• Identify principal diagnosis and complications reflecting acuity and mortality risk.
• Collaborate with coding staff to assign DRG and follow up with physicians.
• Provide daily clinical evaluation of medical records including labs, imaging, and treatment plans.
• Educate physicians and staff on documentation opportunities and DRG considerations.
• Maintain and report data per hospital CDI policies and performance measures.
• Demonstrate professional interpersonal relations and adapt to changing workloads.

Skills

Excellent communication

Critical thinking

Problem solving

Interpersonal skills

Analytical thinking

Education

BSN

RN license (Illinois)

Job description

Advocate Health Care is seeking a Clinical Documentation Improvement professional (RN) to enhance chart quality and ensure accurate DRG assignments. You will review patient records, collaborate with physicians and coding staff, and provide daily assessments of clinical documentation, labs, and treatment plans.

Strong communication, critical thinking, and CDI experience are required. Graduate from an accredited nursing program with an Illinois RN license (BSN preferred).