RN Clinical Documentation Specialist - On-Site 3 Days/Week

Advocate Aurora Health; United States; On-site; USD 79,000 - 119,000; Full time

Benefits offered by this job

Health and welfare benefits

Paid Time Off

Educational Assistance Program

Retirement plans with employer match

Job summary

Advocate Health is seeking a Nursing Professional Development/Clinical Documentation Specialist to enhance documentation quality in adult medical/surgical patients. You will collaborate with physicians and the care team, perform chart reviews, and educate on DRG-related documentation to improve care and reimbursement.

The ideal candidate has 5+ years of nursing experience with a BSN and CDI experience is preferred. This on-site position requires in-person work three days per week.

Qualifications

• Graduate from an accredited school of nursing with BSN and 5 years of clinical experience.
• Clinical documentation improvement experience preferred.
• Hospital nursing experience in adult medical/surgical population required.
• ICU or PACU experience preferred.
• Must be able to work on-site 3 days per week.

Responsibilities

• Improves the overall quality and completeness of clinical documentation by chart reviews against guidelines and regulations.
• Communicates with healthcare team to ensure accurate documentation in the medical record.
• Performs follow-up reviews to confirm clarified and recorded documentation.
• Identifies principal diagnoses and complications for accurate acuity and DRG assignment.
• Reviews issues with coding staff to assign working DRG and follows up with physicians as needed.
• Provides daily clinical evaluation of the medical record including tests and treatment plans.
• Confers with physicians to obtain missing or conflicting documentation and educate on severity of illness.
• Evaluates documentation daily in accordance with hospital policies and procedures.
• Gathers data pertinent to findings and outcomes for performance improvement.

Skills

Nursing experience

Communication skills

Critical thinking

Clinical documentation

Teamwork

Education

BSN

Tools

ICD-10 coding

Job description

Advocate Health is seeking a Nursing Professional Development/Clinical Documentation Specialist to enhance documentation quality in adult medical/surgical patients. You will collaborate with physicians and the care team, perform chart reviews, and educate on DRG-related documentation to improve care and reimbursement.

The ideal candidate has 5+ years of nursing experience with a BSN and CDI experience is preferred. This on-site position requires in-person work three days per week.