Clinical Documentation Specialist (RN)

American Addiction Centers • Milwaukee, WI

5d • $38 - $57 • Hybrid

About The Position

Aurora St. Luke’s Medical Center is seeking a detail-oriented, clinically experienced Registered Nurse to join our Clinical Documentation Integrity (CDI) team. This role is ideal for nurses who enjoy clinical problem-solving, collaboration with providers, and ensuring the medical record accurately reflects the complexity of patient care. As a Clinical Documentation Specialist, you will serve as a key partner to physicians, nursing staff, and Health Information Management professionals to improve documentation quality, support accurate coding and reimbursement, and ensure the patient's severity of illness is appropriately captured.

Requirements

• Registered Nurses (RN) with a minimum of 2 years of recent clinical nursing experience
• Current Registered Nurse (RN) license issued by the state of Wisconsin in which the team member practices
• Associate Degree in Nursing (ADN) required
• Strong clinical judgment and critical thinking abilities
• High-acuity patient care experience and the ability to recognize complex clinical presentations
• Knowledge and recognition of medications and treatment regimens
• Strong communication and collaboration skills
• Comfort working in electronic medical records and Microsoft Word
• Ability to work independently while partnering effectively with providers and interdisciplinary teams

Nice To Haves

• preference for candidates with ICU or other high-acuity inpatient experience
• Availability to work on-site two days per week

Responsibilities

• Review inpatient medical records concurrently to ensure accurate, complete, and compliant clinical documentation.
• Conduct comprehensive chart reviews to identify co-morbidities, complications, quality indicators, and opportunities for documentation improvement.
• Collaborate with physicians, nurses, and coding professionals to identify principal and secondary diagnoses, procedures, and appropriate DRG assignments.
• Utilize the physician query process to clarify clinical documentation and accurately reflect patient severity of illness, risk of mortality, and complexity of care.
• Support quality metrics, reimbursement accuracy, and regulatory compliance through effective documentation practices.
• Identify, evaluate, and help resolve barriers to meeting clinical documentation standards.
• Monitor and track Clinical Documentation Integrity (CDI) program outcomes using established tools and reporting processes.
• Identify quality variances and documentation opportunities that can be addressed concurrently during the patient's admission.
• Serve as an educator and resource to physicians and clinical staff regarding documentation requirements, best practices, and query responses.
• Build and maintain positive working relationships across interdisciplinary teams while promoting documentation excellence and problem-solving.

Benefits

• Paid Time Off programs
• medical
• dental
• vision
• life
• Short- and Long-Term Disability
• Flexible Spending Accounts for eligible health care and dependent care expenses
• adoption assistance
• 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
• Education Level: Associate degree