RN Clinical Documentation Specialist — CDI & Coding Expert

Advocate Health; Park Ridge (IL); On-site; USD 90,000 - 110,000; Full time

Job summary

Advocate Health seeks a Clinical Documentation Improvement Specialist (RN) to enhance chart accuracy and coding integrity. You will collaborate with physicians and coding staff to ensure documentation reflects clinical acuity and regulatory requirements, while leading educational initiatives across internal teams.

Applicants should hold a BSN, possess Illinois RN licensure, and have CDI experience or interest in certification.

Qualifications

• Graduate from an accredited school of nursing.
• Current nursing license in the State of Illinois.
• Certification in clinical documentation improvement preferred.

Responsibilities

• Improve clinical documentation quality by performing chart reviews using clinical guidelines and current regulations.
• Communicate with healthcare team to ensure accurate, complete documentation in the medical record.
• Conduct follow-up reviews to clarify documentation and reflect severity of illness and risk of mortality.
• Identify principal diagnosis and complications to reflect acuity; collaborate with coders to assign DRG.
• Provide daily evaluation of medical records including labs, diagnostics, and treatment plan.
• Consult with physicians on missing or conflicting documentation to obtain needed information.
• Educate internal customers on documentation opportunities, coding, reimbursement, and performance improvement.
• Develop educational strategies for physicians and staff on documentation opportunities and DRG impacts.
• Coordinate education on compliance, coding, and clinical documentation issues.
• Participate in performance improvement activities and maintain knowledge of current standards.

Skills

Prioritization

Communication

Problem solving

Critical thinking

Interpersonal skills

Verbal and written

Stress management

Adaptability

Education

BSN

Job description

Advocate Health seeks a Clinical Documentation Improvement Specialist (RN) to enhance chart accuracy and coding integrity. You will collaborate with physicians and coding staff to ensure documentation reflects clinical acuity and regulatory requirements, while leading educational initiatives across internal teams.

Applicants should hold a BSN, possess Illinois RN licensure, and have CDI experience or interest in certification.