Clinical Documentation Specialist, Outpatient - Full-Time Days

University of Chicago • Chicago, IL

402d • Remote

About The Position

The Clinical Documentation Specialist (CDS) at UChicago Medicine is responsible for enhancing the quality and completeness of medical record documentation. This role involves collaborating with healthcare providers to ensure accurate representation of clinical services and patient severity of illness. The CDS will also provide education to the care team regarding clinical documentation standards and practices.

Requirements

• 5-8 years of progressive work experience in Case Management, Med/Surg, or Critical Care Nursing.
• Basic computer skills in word processing and spreadsheet utilization.
• Excellent interpersonal skills for effective physician communication.
• Analytic skills to clinically assess medical records.
• Excellent prioritization and organizational skills.
• Must be an actively licensed Registered Nurse.
• A Bachelor's degree in Nursing.

Nice To Haves

• Master's degree in Nursing.
• CCS coding credential.

Responsibilities

• Review and re-review inpatient medical records for identified payer populations, primarily DRG/Case Rate payment methodology.
• Analyze medical records regarding the clinical status of patients, current treatment plans, and past medical histories.
• Communicate with attending physicians to validate observations and obtain clarification of incomplete or ambiguous documentation.
• Apply knowledge of documentation requirements and guidelines in accordance with ICD-9 CM Official Guidelines for Coding and Reporting.
• Work closely with HIM coding staff to ensure accurate documentation of principal diagnoses and co-existing comorbidities.
• Meet established productivity targets for record review consistently.
• Develop and implement education plans for clinical staff regarding documentation practices.
• Identify strategies for sustained work process changes to facilitate complete and accurate clinical documentation.
• Assume responsibility for job duties in a safe manner and report hazards to management.
• Perform other duties as requested by senior management.

Benefits

• Sign-On Bonus up to $1,500!

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Educational Services
• Education Level: Bachelor's degree