Clinical Documentation Specialist

Medical Record Documentation Specialist

Facilitate improvement in overall quality, completeness and accuracy of medical record documentation.

Complete admission reviews and assign a working Diagnosis Related Group.

Ensure the working DRG and other information are entered in the Clinical Documentation Improvement database.

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's discharge.

Maintain accurate records of review activities, ensuring reports and outcomes of CDI efforts are valid.

Licensure / Certification / Registration: One or more of the following required:

• Certified Coding Specialist (CCS) credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
• Certified Professional Coder (CPC) credentialed from the American Academy of Professional Coders (AAPC) obtained prior to hire date or job transfer date.
• Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.
• Registered Nurse credentialed from the Illinois Department of Financial and Professional Regulation obtained prior to hire date or job transfer date.
• Reg Health Info Admnstr credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
• Reg Health Info Tech credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.

Education: High School diploma equivalency with 2 years of cumulative experience OR Associate's degree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required.

Hybrid position - Flexible with local IL traveling, required (Northwest and Chicago Metro facilities) - must reside in Illinois due to travel requirement.