Clinical Documentation Specialist - RN

University of Chicago Hospital   •  

Chicago, IL

Industry: Education.


5 - 7 years

Posted 262 days ago

This job is no longer available.

Job Description

Bring Your Passion to the Forefront:

Clinical Documentation Specialist - RN

Join one of the nation’s most comprehensive academic medical centers, University of Chicago Medicine, in a process improvement-driven and innovative role as the Clinical Documentation Specialist with our Health Information Management division.

 Our employees deliver world-class care in an environment where opinions are respected, decision-making is rewarded and teamwork is the order of the day. Our staff is encouraged to achieve their career goals, which in turn benefits all of our patients and the University of Chicago Medicine as a whole.

The Clinical Documentation Specialist (CDS) is responsible for facilitating improvement in the overall quality and completeness of medical record documentation on a concurrent basis. 

The CDS promotes modifications to medical record documentation to ensure accurate depiction of the level of clinical services provided to the patient and to completely describe patients’ severity of illness.

The CDS obtains appropriate clinical documentation through collaborative communications from having developed positive working relationships with physicians, nursing staff, otherpatient care providers, and the Health Information Management Department Coders.

The CDS is also responsible for providing informal and formal education to all members of the care team regarding clinical documentation.

Responsibilities include:

  • Reviews and re-reviews inpatient medical records for identified payer populations (primarily DRG/Case Rate payment methodology) beginning approximately 48 after admission. Analyzes the medical record regarding the clinical status of patient, current treatment plan and past medical history and seeks clarification of incomplete, unclear, and ambiguous clinical documentation.
  • Communicates with attending physician(s) verbally and through written methodology to validate observations, and obtain clarification of incomplete, unclear, and ambiguous documentation including clarification of POA.
  • Demonstrates and applies basic knowledge of documentation requirements and guidelines in accordance with ICD-10 CM/PCS Official Guidelines for Coding and Reporting.
  • Works closely with HIM coding staff to assure documentation of principal diagnosis and any co-existing comorbidities and complications accurately reflect the patient’s clinical status and level of services provided. Reviews attestation of all billed diagnoses and procedures and reports discrepancies to HIM coding staff.
  • Consistently meets established productivity targets for record review.
  • In collaboration with physician leadership, designs and implements specific tools to support physician documentation requirements.
  • Develops and implements plans for both formal and informal education of physician, nursing and other clinical staff.
  • Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation.
  • Maintains the confidentiality of information acquired pertaining to patient, physicians, associates, and visitors. Discusses patient and hospital information only among appropriate personnel in private and appropriate settings.
  • Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of co-workers, and to report all preventable hazards and unsafe practices immediately to management.
  • Performs other duties as requested by senior management.

You'll thrive in this position if you:

  • Accelerate Change – you quickly recognize the various inputs that impact successful results; you determine steps required to achieve successful outcomes; adjusts work and timelines as needs and priorities change; motivates others to gain commitment. You apply understanding of industry, UCMC and one’s own role to successfully advance the organization’s performance. You recognize the potential of continuous improvement and utilize the 5S methodology.
  • Deliver Results – you establish a vision how to achieve superior results, create challenging goals that are aligned to the vision; clearly communicate expectations and gain agreement. You maintain self-discipline; follow-up consistently and regularly; measure progress and evaluate results; reprioritize as appropriate; prevent irrelevant issues from creating distractions. You work tenaciously to overcome obstacles and to meet or exceed goals; you adjust resources to achieve priorities; take pride in delivering superior results; hold others accountable for their actions. You enlist others to move toward higher levels of performance; generate enthusiasm for potential accomplishments.
  • Promote Innovation – you combine ideas in a unique way or make connections between ideas that may appear to be different; explore situations from multiple perspectives, seek alternative ways to define problems. You are open to diverse thoughts and approaches by others. You test solutions, gather feedback on effectiveness, review impact on the results and modify appropriately to product expected results.
  • Communicate with Impact– you focus on the message of others, provide undivided attention, and defer judgment. You convey messages logically, simply, and with confidence. You check for understanding by asking questions, seeking clarity and responding accordingly.

Required Qualifications:

  • Must have a Bachelor’s degree in Nursing from an accredited academic body.
  • Must be actively licensed as a Registered Nurse within the state of Illinois.
  • Must have a minimum of five years' progressive work experience working as a Registered Nurse.
  • Must have basic computer skills in word processing and spreadsheet utilization.
  • Must have excellent interpersonal skills necessary to develop and foster effective physician communication.
  • Must have the analytic skills necessary to clinically assess medical records.
  • Must have excellent prioritization and organizational skills.

Preferred Qualifications:

  • Holding the CCS coding credential is preferred.
  • Holding a Master’s degree in Nursing or anotherhealthcare-related field is preferred.
  • Experience working in Case Management, Med/Surg, or Critical Care Nursing preferred..

Job ID 2017-11119