Clinical Documentation Specialist - RN

at  Ascension

DETAILS

• Department: Quality Management
• Schedule: Full Time, Monday - Friday
• Hospital: Ascension Saint Mary - Chicago
• Location: Chicago, IL 60622

REQUIREMENTS

Licensure / Certification / Registration:

• Registered Nurse credentialed from the Illinois Board of Nursing obtained prior to hire date or job transfer date required.

Education:

• Diploma from an accredited school/college of nursing OR required professional licensure at time of hire.

Facilitate improvement in overall quality, completeness, and accuracy of medical record documentation.

• Complete admission reviews and work closely with coding staff to ensure accuracy in code assignments that reflect the patients clinical status and care.
• Initiate and maintain extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record.
• Collaborate with healthcare professionals to ensure the severity of illness and level of services provided are accurately reflected in the medical record and to resolve physician queries and documentation issues prior to patient’s discharge.
• Maintain accurate records of review activities, ensuring reports and outcomes of clinical documentation improvement (CDI) efforts are valid.
• Provide education to the healthcare team on an ongoing basis regarding documentation opportunities, coding, and reimbursement issues, and relevant quality and performance improvement activities.