Clinical Documentation Specialist

4 weeks ago

Chicago, United States The University of Chicago Medicine Full time

**Job Description**:
**Bring Your Passion to the Forefront**:
**Clinical Documentation Specialist (OUTPATIENT)
- Full Time Days, University of Chicago Medicine in Hyde Park, Chicago, IL**

Join one of the nation’s most comprehensive academic medical centers, University of Chicago Medicine, in a process improvement-driven and innovative role as a **Clinical Documentation Specialist (OUTPATIENT)** 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.

In this role, the **Clinical Documentation Specialist (OUTPATIENT)** (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, other patient 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.

**Clinical Documentation Specialist Education and Experience Requirements**:

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

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