Clinical Documentation Specialist

About This Role

This hybrid role involves improving the quality and completeness of medical record documentation on an ongoing basis. The specialist promotes modifications to ensure accurate depiction of clinical services and patient severity of illness, working collaboratively with physicians, nursing staff, and the Health Information Management Department. The position also involves educating the care team on clinical documentation.

Responsibilities

• Communicate with attending physician(s) verbally and through written methodology to validate observations and obtain clarification of incomplete, unclear, and ambiguous documentation, including clarification of POA
• Demonstrate and apply basic knowledge of documentation requirements and guidelines in accordance with ICD-10 CM Official Guidelines for Coding and Reporting
• Consistently meet established productivity targets for record review
• Design and implement specific tools to support physician documentation requirements in collaboration with physician leadership
• Maintain the confidentiality of information acquired pertaining to patients, physicians, associates, and visitors
• Discuss patient and hospital information only among appropriate personnel in private and appropriate settings
• Assume responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of co-workers, and to report all preventable hazards and unsafe practices immediately to management

Requirements

• Analytic skills necessary to clinically assess medical records
• Bachelor's Degree
• IL RN License
• Basic computer skills in word processing and spreadsheet utilization
• Excellent interpersonal skills necessary to develop and foster effective physician communication

Nice to have:

• 5-8 years’ experience in Case Management or Med/Surg or Critical Care nursing experience
• Master's Degree
• CCS coding credential

Important Details

• Shift: Days – 8-hour shift
• Unit/Department: Medical Records
• CBA Code: Non-Union

About the Company

UChicago Medicine is a world-class academic healthcare system.