Clinical Documentation Specialist - Summit

M-F Business hours, hybrid position, on site 3 days a week remote 2 days a week

Pay Range

Responsible for concurrent review of the clinical documentation in the medical records and query of the medical staff and other caregivers as necessary, via query process to obtain accurate and complete documentation which appropriately supports the severity of patient illness. This position will facilitate improvement in documentation through interaction with physicians and other members of the healthcare team.

Conducts initial concurrent review process for all selected admissions to initiate the tracking process and identification of other key pathway or quality indicators as appropriate.

In collaboration with the physician, nurse, and Medical Records coder, identifies and records principle and secondary diagnoses, principle procedures, and assigns a working Diagnosis Related Group (DRG).

Identifies need to clarify clinical documentation in records, and initiates communication with the provider by utilizing the query process, in order to capture the documentation in the medical record that supports patient's severity of illness.

Serves as an educator and resource to the medical staff and hospital staff regarding clinical documentation requirements.

Promotes effective professional relationships with physicians, other department members and hospital staff; facilitates problem solving as appropriate.

Identifies, evaluates, and acts to resolve any barriers to meeting documentation standards.

Performs a thorough chart review to identify co-morbidities / complications and documents these appropriately on the clinical documentation worksheet.

Utilizes monitoring tools to track the progress of the Clinical Documentation Assurance Program.

Identifies quality variances that can be abstracted concurrently.

Provides information and education as necessary to physicians and ancillary staff not responding to queries.

Licenses & Certifications

Registered Nurse license issued by the state in which the team member practices.

Degrees

Associate's Degree in Nursing.

Required Functional Experience

Typically requires 3 years of experience in an acute inpatient environment.

Knowledge, Skills & Abilities

Ability and desire to learn and develop skills necessary to perform the Clinical Documentation Program. Knowledge of Clinical Documentation payor issues including requirements and reimbursement policies helpful.Working knowledge of Medicare reimbursement and coding structures.Knowledge of care delivery documentation systems and related medical record documents.Excellent analytical and interpersonal communication skills necessary to collaborate with physicians and health information staff.Demonstrated ability to work well with physicians and other professionals in a direct and positive manner. Excellent written and verbal communication and critical thinking skills.

Our Commitment to You:

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