RN Clinical Documentation Specialist

The Clinical Documentation Specialist is responsible for improving the overall quality and completeness of clinical documentation to ensure accurate coding, appropriate reimbursement, and compliance with regulatory requirements. This role involves working closely with physicians, healthcare providers, and coding staff to clarify and enhance the documentation of clinical information.

• Position: Clinical Documentation Specialist

• Location: Hybrid – Skokie, IL and remote

• Full Time/Part Time: Full Time (40 hours per week)

• Hours: Monday-Friday, 8:00am-4:30pm

• Required Travel: required travel to other Endeavor Health locations for in person trainings and meetings

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  Review medical records concurrently to ensure accuracy, completeness, and specificity of clinical documentation.

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  Identify and clarify missing, conflicting, or nonspecific physicians’ documentation through queries and follow up.

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  Collaborate with healthcare providers to ensure accurate and comprehensive documentation of patient diagnoses and treatments.

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  Develop and implement effective query to resolve documentation issues.

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  Ensure queries are clear, concise, and compliant with industry’s standards and regulatory requirements.

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  Track and follow up on outstanding queries to ensure timely responses.

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  Query format and questions meet AHIMA and ACIDS guideline.

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  Ensures adherence to professional standards, quality standards, licensure, and federal laws.

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  Ensure clinical documentation complies with all applicable regulations and standards, including those set by CMS, Joint Commission, and other governing bodies.

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  Provide education to the physicians and other clinical staff on documentation best practice and importance of accurate clinical documentation

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  Attend education programs, workshops, and one-one-one training to enhance continuous learning.

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  Participate in professional organization such as the Clinical Documentation Improvement Specialist (ACDIS) or the American Health Information Management.

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  Actively engage in mentoring relationships to support less experienced colleagues and contribute to professional development within the team.

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  Education: Associate in Nursing or HIM is required. Bachelor’s degree in nursing is preferred

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  Certification: ADN or RHIT; IL Licensed RN Preferred

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  Experience: 3-5 years RN experience in an Acute Care Hospital (critical care preferred)

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  Unique or Preferred Skills:

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    Strong clinical knowledge and demonstrated commitment to maintaining relevancy in the clinical field. 

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    Excellent analytical and communication skills.

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    Ability to work independently and collaboratively in a team environment.  

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    Proficient in using electronic medical record (EMR) and clinical tools.

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    Familiarity with healthcare regulations, including HIPAA, and documentation standards

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    Proficient in using office software (e.g., Microsoft Office Suite, excel) and other communication platforms (e.g., email, video conferencing) for collaboration and reporting.