Clinical Documentation Spec-RN

Advocate Health and Hospitals Corporation • Park Ridge, IL

4d • Hybrid

About The Position

This full-time position focuses on improving the overall quality and completeness of clinical documentation within the hospital setting. The Clinical Documentation Specialist will perform chart reviews using established guidelines, communicate with healthcare team members to ensure accuracy, and conduct follow-up reviews to confirm documentation updates. The role involves identifying the principal diagnosis and complications, reviewing clinical issues with coding staff, and providing daily clinical evaluations of medical records. A key aspect of this role is conferring with physicians, both in person and through documentation inquiry forms, to clarify information, obtain necessary documentation, and educate on appropriate identification of severity of illness. The specialist will also be responsible for educating internal customers on clinical documentation opportunities, coding and reimbursement issues, and performance improvement strategies. This role requires a strong understanding of DRG payer issues, clinical documentation requirements, and coding policies. The specialist will develop and coordinate educational strategies for physicians and the healthcare team, acting as a consultant to coders when additional information is needed. Participation in continuous performance improvement, maintaining knowledge of current standards of care, and completing required educational programs are also essential. The role involves maintaining database integrity, tracking trends, and reporting on clinical documentation outcomes. Promoting patient safety and demonstrating positive interpersonal relations are crucial. This position requires in-person work with physicians and other allied health professionals and is not a remote role, with a hybrid work requirement.

Requirements

• Graduate from an accredited school of nursing
• BSN
• 5 years relevant clinical experience (For associates in process level 25013, 5 years relevant pediatric clinical experience)
• Strong clinical skills are necessary to be successful in this role.
• Extensive knowledge and experience of ICD-10 coding classification system and DRGs
• Ability to prioritize work
• Excellent communication skills
• Good problem solving skills
• Critical thinking skills
• Basic Computer skills
• Effective problem-solver with good interpersonal communication skills, verbal and written
• Effective observation, analytical, and critical thinking skills
• Current nursing license in the State of Illinois.

Nice To Haves

• Hospital nursing experience in pediatric patient population.
• NICU, PICU or Specialty PEDS experience.
• Clinical documentation improvement experience preferred.
• Certification in clinical documentation improvement preferred.

Responsibilities

• Improves the overall quality and completeness of clinical documentation by performing chart reviews using clinical documentation guidelines based on accepted standards, evidenced based practice, and current regulatory requirements.
• Communicates with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record.
• Conducts follow-up reviews of clinical documentation to ensure points of clarification and agreed upon documentation have been recorded in the patient’s chart.
• Identifies the most appropriate principal diagnosis and complications including date to accurately reflect clinical acuity and risk of mortality in compliance with government regulations.
• Reviews clinical issues with coding staff to assign a working DRG, follows up with physicians if appropriate.
• Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plan.
• Confers with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness.
• Responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital’s designated clinical documentation policies and procedures.
• Gather and analyze information pertinent to documentation findings and outcomes.
• Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement strategies.
• Demonstrates knowledge of DRG payer issues, documentation opportunities, clinical documentation requirements, coding and policies and procedures.
• Develops educational strategies for physicians and other members of the healthcare team regarding identified documentation opportunities to help support clinical acuity and risk of mortality within the medical record and to understand the significance of appropriate documentation.
• Coordinates education to all internal customers related to compliance, coding, and clinical documentation issues.
• Acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG.
• Participates in continuous performance improvement and completes all required educational programs for hospital and medical staff.
• Maintains knowledge of current standards of care via literature review and participation in educational offerings.
• Research literature to identify new methods development and overall documentation enhancement.
• Complete required contact hours based on FTE status, within time frame.
• Maintains the integrity of data bases, tracks and trends response to clinical documentation and measures for performance improvement.
• Assist site CDI leader in the development and reporting of performance measures to the medical staff and other departments and prepare physician specific data information, as appropriate.
• Completes documentation on reviewed cases in the database.
• Completes the DRG and query indicators for each reviewed case, as appropriate.
• Promotes patient safety by reporting of issues through established channels and participating as requested in safety initiatives.
• Identify patterns, trends variances and opportunities to improve documentation review and process.
• Demonstrate positive and effective interpersonal relations dealing with all members of the team (ie co-workers, physicians, leadership, etc.).
• Maintains a positive attitude about assignments and team members.
• Promotes professional/personal growth of co-workers by sharing knowledge and resources.
• Manages stress and personal feelings without a negative impact on the team.
• Communicates in a positive and productive manner.
• Demonstrates flexibility with changing workload/assignments.

Benefits

• Comprehensive suite of Total Rewards: benefits and well-being programs
• Competitive compensation
• Generous retirement offerings
• Programs that invest in your career development
• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
• Flexible Spending Accounts for eligible health care and dependent care expenses
• Family benefits such as adoption assistance and paid parental leave
• Defined contribution retirement plans with employer match and other financial wellness programs
• Educational Assistance Program

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level