RN Clinical Documentation Specialist – On-Site 3 Days

Hugh Chatham Health; Park Ridge (IL); On-site; USD 79,000 - 119,000; Full time

Benefits offered by this job

Health benefits

Paid Time Off

Retirement plan

Professional development opportunities

Job summary

Advocate Health is seeking a Nurse CDI professional to improve clinical documentation in the Medical Staff and healthcare team, ensuring compliance with DRG and regulatory requirements. This on-site role requires RN licensure in Illinois with BSN and at least five years of clinical nursing experience.

On-site work three days per week, with hospital nursing background in adult medical/surgical units; ICU/PACU experience preferred.

Qualifications

• Graduate from an accredited school of nursing with active RN license in Illinois.
• BSN is required; minimum 5 years of clinical nursing experience.
• Hospital nursing experience in adult medical/surgical units; ICU/PACU preferred.
• Position requires in-person work with physicians and other health professionals; on-site 3 days/week.

Responsibilities

• Improve the overall quality and completeness of clinical documentation via chart reviews using clinical documentation guidelines.
• Communicate with healthcare team to ensure accurate and complete documentation in the medical record.
• Conduct follow-up reviews to ensure documentation reflects needed clarifications and is recorded.
• Identify principal diagnosis and complications to reflect acuity and mortality risk per regulations.
• Review DRG with coding staff and educate physicians to ensure correct DRG assignment.
• Provide daily clinical evaluation of medical records, labs, diagnostics, and treatment plans.
• Consult with physicians to resolve missing or conflicting documentation.
• Promote patient safety and participate in performance improvement initiatives.

Skills

5+ years nursing experience

BSN

ICU/PACU experience preferred

Adult medical/surgical

Education

BSN degree

Job description

Advocate Health is seeking a Nurse CDI professional to improve clinical documentation in the Medical Staff and healthcare team, ensuring compliance with DRG and regulatory requirements. This on-site role requires RN licensure in Illinois with BSN and at least five years of clinical nursing experience.

On-site work three days per week, with hospital nursing background in adult medical/surgical units; ICU/PACU experience preferred.