Clinical Documentation Specialist

1 day ago


Chicago, Illinois, United States Ascension Full time
Job Summary

We are seeking a highly skilled Clinical Documentation Specialist to join our team at Ascension. As a key member of our Quality Management department, you will play a critical role in ensuring the accuracy and completeness of medical record documentation.

Responsibilities
  • Collaborate with healthcare professionals to ensure the severity of illness and level of services provided are accurately reflected in the medical record.
  • Initiate and maintain extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record.
  • Complete admission reviews and work closely with coding staff to ensure accuracy in code assignments that reflect the patients clinical status and care.
  • 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.
Requirements
  • Registered Nurse credentialed from the Illinois Board of Nursing obtained prior to hire date or job transfer date required.
  • Diploma from an accredited school/college of nursing OR required professional licensure at time of hire.
Preferred Qualifications
  • BSN
  • CDI experience preferred
  • CCDS certification preferred
  • 4+ years of acute care RN experience, ICU preferred
About Ascension

Ascension 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.

We are committed to delivering compassionate, personalized care to all, and we are seeking talented individuals like you to join our team.



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