Clinical Documentation Specialist (RN)

American Addiction Centers • Libertyville, IL

1d • $38 - $56 • Hybrid

About The Position

This is not a remote position, requires 3 days per week in office. Adult Critical Care Experience strongly preferred. This role will facilitate the modifications of clinical documentation through extensive initial and concurrent interaction with physicians and other members of the healthcare team, to support appropriate documentation of the clinical severity and risk of mortality is captured for the level of services rendered to select inpatients populations. This role will supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes and provides education to all members of the health care team on an ongoing basis.

Requirements

• Licensure: Nurse, Registered (RN)
• Education/Experience Required: 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)
• Knowledge, Skills & Abilities Required: 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

• 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.
• 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
• 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
• 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.
• Gather and analyze information pertinent to documentation findings and outcomes
• 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
• 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
• 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
• 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.
• 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

• Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including:
• Compensation Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training
• Premium pay such as shift, on call, and more based on a teammate's job
• Incentive pay for select positions
• Opportunity for annual increases based on performance
• Benefits and more 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
• Number of Employees: 11-50 employees