Clinical Documentation Specialist

Department:

10169 Aurora Lakeland Medical Center - Clinical Documentation Improvement

Status:

Full time

Benefits Eligible:

Yes

Hours Per Week:

40

Schedule Details/Additional Information:

Hybrid position, minimum of 3 days on-site a week after initial orientation

Monday - Friday, flexible star

Major Responsibilities:

• Conducts initial concurrent review process for all selected admissions to initiate the tracking process and identification of other key pathway or quality indicators as appropriate.
• In collaboration with the physician, nurse, and Medical Records coder, identifies and records principle and secondary diagnoses, principle procedures, and assigns a working Diagnosis Related Group (DRG).
• Identifies need to clarify clinical documentation in records, and initiates communication with the provider by utilizing the query process, in order to capture the documentation in the medical record that supports patient's severity of illness.
• Serves as an educator and resource to the medical staff and hospital staff regarding clinical documentation requirements.
• Promotes effective professional relationships with physicians, other department members and hospital staff; facilitates problem solving as appropriate.
• Identifies, evaluates, and acts to resolve any barriers to meeting documentation standards.
• Performs a thorough chart review to identify co-morbidities / complications and documents these appropriately on the clinical documentation worksheet.
• Utilizes monitoring tools to track the progress of the Clinical Documentation Assurance Program.
• Identifies quality variances that can be abstracted concurrently.
• Provides information and education as necessary to physicians and ancillary staff not responding to queries.

Licensure, Registration, and/or Certification Required:

• Registered Nurse license issued by the state in which the team member practices.

Education Required:

• Associate's Degree in Nursing. Bachelor's preferred.

Experience Required:

• Typically requires 3 years of experience in an acute inpatient environment.

Knowledge, Skills & Abilities Required:

• Ability and desire to learn and develop skills necessary to perform the Clinical Documentation Program.
• Knowledge of Clinical Documentation payor issues including requirements and reimbursement policies helpful.
• Working knowledge of Medicare reimbursement and coding structures.
• Knowledge of care delivery documentation systems and related medical record documents.
• Excellent analytical and interpersonal communication skills necessary to collaborate with physicians and health information staff.
• Demonstrated ability to work well with physicians and other professionals in a direct and positive manner.
• Excellent written and verbal communication and critical thinking skills.
• Attention to detail
• Clinical skills

Physical Requirements and Working Conditions:

• Manual dexterity required for operation computer and calculator.
• Visual acuity required to facilitate review of written documents/computer screens, medical records, and to record information accurately.
• Clear oral communications and hearing acuity required for receiving instructions and converse on standard telephone.
• Functional speech and hearing to allow for effective communication of instructions and conversation over the telephone.
• Exposed to a normal office environment.
• Operates all equipment necessary to perform the job.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.

Pay Range

$37.50 - $56.25

Our Commitment to You:

Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including:

Compensation

• Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training
• Premium pay such as shift, on call, and more based on a teammate's job
• Incentive pay for select positions
• Opportunity for annual increases based on performance

Benefits and more

• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
• Flexible Spending Accounts for eligible health care and dependent care expenses
• Family benefits such as adoption assistance and paid parental leave
• Defined contribution retirement plans with employer match and other financial wellness programs
• Educational Assistance Program

About Advocate Health 

Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.