Clinical Documentation Specialist- Full Time

Found in: Talent US C2 - 2 weeks ago

Libertyville, United States 124 Advocate Condell Medical Center Full time

Department:

11206 Advocate Condell Medical Center - Clinical Document Management Program

Status:

Full time

Benefits Eligible:

Yes

Hou rs Per Week:

40

Schedule Details/Additional Information:

Candidate must be willing to work hybrid (on-site & remote days). On-site requirement is 6 days minimum per 2 week (pay period). Weekend work requirement. Candidate would be required to work approximately 1 weekend every month to month and half. Must have acute care facility clinical bedside nursing experience of either medical, surgical, or intensive care. Will not consider candidates with only psychiatry, pediatric, outpatient clinic / medical office, or obstetric experience.

Major Responsibilities:

Improves the overall quality and completeness of clinical documentation by performing chart reviews using clinical documentation guidelines based on accepted standards, evidenced based practice, and current regulatory requirements. 1)Responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital’s designated clinical documentation policies and procedures 2)Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plan 3)Confers with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness 4)Communicates with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record 5)Conducts follow-up reviews of clinical documentation to ensure points of clarification and agreed upon documentation have been recorded in the patient’s chart. 6)Identifies the most appropriate principal diagnosis and complications including date to accurately reflect clinical acuity and risk of mortality in compliance with government regulations 7)Reviews clinical issues with coding staff to assign a working DRG, follows up with physicians if appropriate. 8)Gather and analyze information pertinent to documentation findings and outcomes Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement strategies. 1)Demonstrates knowledge of DRG payer issues, documentation opportunities, clinical documentation requirements, coding and policies and procedures. 2)Develops educational strategies for physicians and other members of the healthcare team regarding identified documentation opportunities to help support clinical acuity and risk of mortality within the medical record and to understand the significance of appropriate documentation 3)Coordinates education to all internal customers related to compliance, coding, and clinical documentation issues. Acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG 4)Acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG 5)Participates in continuous performance improvement and completes all required educational programs for hospital and medical staff 6)Maintains knowledge of current standards of care via literature review and participation in educational offerings 7)Research literature to identify new methods development and overall documentation enhancement 8)Complete required contact hours based on FTE status, within time frame Maintains the integrity of data bases, tracks and trends response to clinical documentation and measures for performance improvement. 1)Completes documentation on reviewed cases in the database. 2)Completes the DRG and query indicators for each reviewed case, as appropriate. 3)Promotes patient safety by reporting of issues through established channels and participating as requested in safety initiatives. 4)Identify patterns, trends variances and opportunities to improve documentation review and process5)Assist site CDI leader in the development and reporting of performance measures to the medical staff and other departments and prepare physician specific data information, as appropriate. Demonstrate positive and effective interpersonal relations dealing with all members of the team (i.e. co-workers, physicians, leadership, etc.). 1)Maintains a positive attitude about assignments and team members 2)Promotes professional/personal growth of co-workers by sharing knowledge and resources. 3)Manages stress and personal feelings without a negative impact on the team 4)Communicates in a positive and productive manner. 5)Demonstrates flexibility with changing workload/assignments.


Licensure:

Nurse, Registered (RN)


Education/Experience Required:

Graduate from an accredited school of nursing BSN 5 years relevant clinical experience (For associates in process level 25013, 5 years relevant pediatric clinical experience) Clinical documentation improvement experience preferred


Knowledge, Skills & Abilities Required:

Ability to prioritize work Excellent communication skills Good problem solving skills Critical thinking skills Basic Computer skills Effective problem-solver with good interpersonal communication skills, verbal and written Effective observation, analytical, and critical thinking skills Current nursing license in the State of Illinois. Certification in clinical documentation improvement preferred.


Physical Requirements and Working Conditions:

Ability to work in changing environment Ability to prioritize independently and respond to multiple simultaneous requests Ability to work under stressful conditions and in difficult situations May be exposed to hazardous materials and life threatening diseases This position needs to recognize needs and behaviors of specific age groups of patients treated. Extensive knowledge and experience of ICD-10 coding classification system and DRGs none

  • General Surgery Full-Time position in Libertyville, Illinois

    Found in: beBee S US - 3 weeks ago

    Libertyville, United States Advocate Aurora Health Care Full time

    Join one of the nation’s largest, most respected health systems and experience what it means to live well. Advocate Health is seeking a board certified trauma and acute care surgeon to serve its patients at Advocate Condell Medical Center, in Libertyville, Illinois. **Job details** - 1.0 Full-time - Will provide acute general surgery coverage and take...

  • Clinical Supervisor

    2 weeks ago

    Libertyville, United States Youth & Family Counseling Full time

    What are you on a mission to do?At Youth & Family Counseling, we value incredible people with incredible skills, but your commitment to a greater cause is something we value even more.Come join our team where each day you'll be surrounded by dedicated, committed professionals focused on a common goal of making a difference by delivering relationship-based...

  • Benefits Specialist

    2 weeks ago

    Libertyville, United States CareerBuilder Full time

    We Make Life More Rewarding and Dignified Location: Libertyville Department: Human Resources Summary: This position is responsible for several key areas in the day-to-day management, administration, and compliance of U.S. employee benefit plans and programs. The Specialist, Benefits is a subject matter expert, supporting all U.S. domestic sites in resolving...

  • Clinical Supervisor

    6 days ago

    Libertyville, United States Youth & Family Counseling Full time

    What are you on a mission to do? At Youth & Family Counseling, we value incredible people with incredible skills, but your commitment to a greater cause is something we value even more. Come join our team where each day you'll be surrounded by dedicated, committed professionals focused on a common goal of making a difference by delivering relationship-based...

  • Import Specialist

    Found in: Lensa US P 2 C2 - 3 days ago

    Libertyville, United States Rierden Chemical & Trading Company Full time

    Import Specialist At Rierden Chemical, a major component of the value proposition we bring to the market is our focus on logistics.Whether it be simplification of complex international shipping supply chains crossing the globe or ensuring local domestic freight gets where it needs to be when it needs to be, our success at RCT depends on our continued focus...

  • Import Specialist

    Found in: Appcast Linkedin GBL C2 - 6 days ago

    Libertyville, United States Rierden Chemical & Trading Company Full time

    Import Specialist At Rierden Chemical, a major component of the value proposition we bring to the market is our focus on logistics.Whether it be simplification of complex international shipping supply chains crossing the globe or ensuring local domestic freight gets where it needs to be when it needs to be, our success at RCT depends on our continued focus...

  • Import Specialist

    Found in: Appcast US C2 - 7 days ago

    Libertyville, United States Rierden Chemical & Trading Company Full time

    Import Specialist At Rierden Chemical, a major component of the value proposition we bring to the market is our focus on logistics.Whether it be simplification of complex international shipping supply chains crossing the globe or ensuring local domestic freight gets where it needs to be when it needs to be, our success at RCT depends on our continued focus...

  • Clinical Nurse Supervisor Cardiology

    Found in: Talent US C2 - 1 week ago

    Libertyville, United States 125 Advocate Health and Hospitals Corporation Full time

    Department: 02050 AMG Libertyville 825 Milwaukee - Cardiology Status: Full time Benefits Eligible: Yes Hou rs Per Week: 40 Schedule Details/Additional Information: Cardiology/EP CNS for Monday - Friday 8am - 5pm. Major Responsibilities: Ensures effective and quality patient care services Patient satisfaction with services and health care ...

  • General Surgery Full-Time position in Libertyville, Illinois

    Found in: beBee jobs US - 3 weeks ago

    Libertyville, Illinois, United States Advocate Aurora Health Care Full time

    Join one of the nation's largest, most respected health systems and experience what it means to live well. Advocate Health is seeking a board certified trauma and acute care surgeon to serve its patients at Advocate Condell Medical Center, in Libertyville, Illinois.Job details 1.0 Fulltime Will provide acute general surgery coverage and take trauma call at a...

  • Clinical Supervisor/Intern Program Manager

    2 weeks ago

    Libertyville, United States Youth & Family Counseling Full time

    What are you on a mission to do?At Youth & Family Counseling, we value incredible people with incredible skills, but your commitment to a greater cause is something we value even more.Come join our team where each day you'll be surrounded by dedicated, committed professionals focused on a common goal of making a difference by delivering relationship-based...

  • Clinical Supervisor/Intern Program Manager

    4 days ago

    Libertyville, United States Youth & Family Counseling Full time

    What are you on a mission to do? At Youth & Family Counseling, we value incredible people with incredible skills, but your commitment to a greater cause is something we value even more. Come join our team where each day you'll be surrounded by dedicated, committed professionals focused on a common goal of making a difference by delivering relationship-based...

  • Branch Manager

    2 weeks ago

    Libertyville, United States BankFinancial Full time

    Job DescriptionJob DescriptionSummary: Meets the Bank's business objectives by developing business opportunities to grow market share, meet sales quotas, cross sell to existing and new customers and manage the branch staff. Builds customer relationships and recognizes potential opportunities by making quality referrals to internal departments of the...

  • Licensed Mental Health Therapist

    3 days ago

    Libertyville, United States Geode Health Full time

    Geode Health is a rapidly growing, national provider of outpatient mental health services. Our mission is 'To empower our patients to live healthier, more rewarding lives through access to exceptional care tailored to their needs.' We are looking for passionate Therapists for both full and part time roles.  The ideal candidate will be motivated by joining...

  • Full Time Occupational Therapist

    Found in: Talent US A C2 - 2 weeks ago

    Libertyville, United States Soliant Full time

    Minimum 1+ years occupational therapy experience required.Soliantis actively seeking a dedicated and skilled Occupational Therapist in the Libertyville, ILarea, to join our team on a contractual basis for a school-based role. If you have a passion for positively influencing the lives of children and thrive in a collaborative environment, we invite you to get...

  • CSV Specialist

    3 days ago

    Libertyville, United States Katalyst Healthcares & Life Sciences Full time

    Responsibilities: Provide support and enhancements for the administration of benchtop instrumentation applications, PC hardware, and IT administrative tools within a GxP environment. Support would encompass various instrument types such as cellometers, plate readers, and flow cytometers throughout the site which include laboratory and...

  • Dialysis Clinical Coordinator

    6 days ago

    Libertyville, United States Encompass Health Full time

    The Hemodialysis Coordinator is responsible for: - Directing, organizing and developing all hemodialysis services - Supervising care, treatment and services of patient care provided by other dialysis staff - Assessing and reassessing patients - Communicating appropriate information with the interdisciplinary team - Reporting patient concerns and changes in...

  • Part-time Recreation Coordinator

    5 days ago

    Libertyville, United States Village of Libertyville Full time

    **Hiring Range**:$20.00-$35.00 DOQ **Benefits**: IMRF eligible, Paid Holiday Leave, 457 Retirement Plans **Closing Date**: Open Until Filled **Education and Experience**: Bachelor's Degree in recreation administration, education, or a related field is preferred. Minimum high school diploma or equivalent required. Minimum of one year of experience in...

  • Nurse Supervisor

    7 days ago

    Libertyville, United States Encompass Health Full time

    In your role as nurse supervisor, youll be the connection between more personal, exceptional care and the positive effect it has on patients. Take this chance to have an impact on each patient in a more profound way during their stay with us. Make the most of your clinical and management skills with national post-acute care leader Encompass Health. NURSE...

  • Speech Pathologist

    4 days ago

    Libertyville, United States Encompass Health Full time

    Speech Pathologist Career Opportunity Welcome to Encompass Health: Where Compassion Meets Speech TherapyAre you searching for a career that aligns with your passion and brings fulfillment close to home? At Encompass Health, we greet you like an old friend, fostering a sense of belonging right from the beginning. Imagine the chance to make a profound...

  • Computer System Validation Engineer

    2 weeks ago

    Libertyville, United States TechDigital Corporation Full time

    PURPOSE AND SCOPE OF POSITION: The Manufacturing IT Systems Quality & Compliance Specialist Cell Therapy Manufacturing Systems supports the successful operation of manufacturing and business functions at Libertyville site through interaction with internal team members, peer and higher-level customers as well as external service providers. The individual is...