Clinical Documentation Specialist RN

American Addiction Centers • Libertyville, IL

2d • $38 - $57 • Hybrid

About The Position

Advocate Condell offers a full spectrum of medical services and is the largest health care provider and only Level 1 trauma center in Lake County, IL. It is also home to Lake County’s first and only comprehensive Trauma Recovery Center and features an emergency department accredited in geriatric and pediatric care. This position ensures clinical documentation accurately reflects patient conditions and care provided, supporting quality outcomes, regulatory compliance, appropriate reimbursement, and organizational performance.

Requirements

• Registered Nurse
• Graduate from an accredited school of nursing BSN
• 5 years relevant clinical experience
• Extensive knowledge and experience of ICD-10 coding classification system and DRGs

Nice To Haves

• Clinical documentation improvement experience preferred
• For associates in process level 25013, 5 years relevant pediatric clinical experience

Responsibilities

• Perform daily reviews of medical records, including physician documentation, lab results, diagnostic testing, and treatment plans.
• Evaluate documentation for accuracy, completeness, severity of illness, risk of mortality, and compliance with clinical documentation standards and regulations.
• Identify opportunities for documentation improvement and ensure the most appropriate principal diagnosis, complications, and comorbidities are captured.
• Conduct follow-up reviews to ensure documentation clarifications have been completed and reflected in the patient record.
• Collaborate with physicians and healthcare team members to clarify missing, conflicting, or incomplete documentation.
• Utilize clinical documentation queries and direct communication to obtain necessary documentation.
• Educate providers on documentation practices that support accurate representation of patient acuity and outcomes.
• Foster strong working relationships with physicians, coders, leadership, and other stakeholders.
• Review clinical records with coding staff to establish working DRGs and ensure accurate code assignment.
• Serve as a resource and consultant to coders when additional documentation is needed.
• Maintain expertise in DRG methodologies, reimbursement requirements, coding guidelines, and regulatory standards.
• Support compliance with government regulations and organizational policies.
• Develop and deliver education for physicians, coders, and clinical staff regarding documentation requirements, coding implications, and reimbursement issues.
• Research best practices and emerging trends in clinical documentation improvement.
• Participate in continuous performance improvement initiatives and required professional development activities.
• Maintain current knowledge through literature review and continuing education.
• Document case reviews and maintain CDI database records.
• Track DRG assignments, query activity, provider responses, and documentation outcomes.
• Analyze trends, variances, and opportunities for improvement in documentation processes.
• Assist CDI leadership in developing performance metrics, reports, and physician-specific feedback.
• Demonstrate effective communication, professionalism, and collaboration with all team members.
• Maintain a positive attitude, adaptability, and flexibility in managing changing priorities.
• Support team development by sharing knowledge and resources.
• Promote patient safety and participate in organizational quality and safety initiatives.

Benefits

• 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