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Clinical Documentation Specialist
1 month ago
We are seeking a skilled Clinical Documentation Specialist to join our team at Ascension Health. As a key member of our quality assurance team, you will play a vital role in ensuring the accuracy and completeness of medical records.
Responsibilities- 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 patient's 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 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.
- 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.
- BSN
- CDI experience preferred
- CCDS certification preferred
- 4+ years of acute care RN experience, ICU preferred
Ascension Health is a leading non-profit, faith-based national health system made up of over 134,000 associates and 2,600 sites of care, including more than 140 hospitals and 40 senior living communities in 19 states. Our Mission, Vision and Values encompass everything we do at Ascension. Every associate is empowered to give back, volunteer and make a positive impact in their community. Ascension careers are more than jobs; they are opportunities to enhance your life and the lives of the people around you.
Ascension is an equal employment opportunity employer and will provide equal employment opportunities to all associates and applicants for employment regardless of race, color, religion, national origin, citizenship, gender, sexual orientation, gender identification or expression, age, disability, marital status, amnesty, genetic information, carrier status or any other legally protected status or status as a covered veteran in accordance with applicable federal, state and local laws.
