at NorthShore University Health System in Elmhurst, Illinois, United States
Job Description
Position Highlights:
Position: Clinical Documentation Specialist
Location: Elmhurst, IL
Full Time/Part Time: Full-time
Hours: Monday-Friday 8:00am-5:00pm
Job Summary
Facilitates integrity in the overall quality, completeness and accuracy of medical record documentation. Obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers and Medical Records coding staff to ensure the clinical documentation reflects the level of service rendered to patients and is complete and accurate. Educates all members of the patient care team on documentation guidelines on an ongoing basis.
What you will do:
Reviews clinical documentation and facilitates clarifications, as needed, to ensure that documentation accurately reflects the reason for admission, intensity of service rendered, risk of mortality, severity of illness, and conditions present on admission for all patients, in compliance with government regulations and ACDIS/AHIMA practice standards.
Initiates inpatient chart review of provider documentation, lab and diagnostic treatment results, and plans of care typically within 48 hours of admission.
Conducts follow-up reviews at regular intervals, in general not to exceed 4 days, to ensure that the working DRG is accurate and documentation is complete.
Conducts retrospective review of cases when requested by the HIM coding team. Reviews may include evaluation of mortalities for complete documentation, and cases with triggered patient safety indicators and hospital acquired conditions to ensure that they are accurately assigned.
Develops queries per departmental guidelines when opportunities to clarify documentation are identified. Follows up with physician or advanced practice clinician to ensure that queries are completed.
Initiates referrals to staff in the quality department when potential issues are identified during review.
Records and maintains an ongoing record of the results of each chart review in the dedicated CDI data base.
Serves as a resource to physicians and other members of the healthcare team in matters relating to DRG assignment, ICD 10 code assignment, and assignment of SOI/ROM scores.
Maintains a level of practice demonstrating knowledge and understanding of AHIMA Practice Briefs, ACDIS Code of Ethics, and official Coding Guidelines
Reconciles DRG discrepancies collaboratively with HIM team to ensure an accurate compilation of the final codes.
Provides periodic informal and formal in-service updates to medical staff and other disciplines on documentation issues using both one-on- one and group forums.
Develops and disseminates approved documentation improvement literature.
Works with HIM, finance and physician groups to develop work systems/processes to facilitate complete documentation for data reporting purposes.
What you will need:
Associates Degree Nursing Required Or
Bachelors Degree Nursing Preferred
5+ Years of clinical (nursing and/or HIM) experience And
1 Year Previous experience in clinical documentation integrity
Registered Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR) Required
Benefits:
Career Pathways to Promote Professional Growth and Development
Various Medical, Dental, Pet and Vision options
Tuition Reimbursement
Free Parking
Wellness Program Savings Plan
Health Savings Account Options
Retirement Options with Company Match
Paid Time Off and Holiday Pay
Community Involvement Opportunities
Endeavor Health is a fully integrated healthcare delivery system committed to providing access to quality, vibrant, community-connected care, serving an area of more than 4.2 million residents across six northeast Illinois counties. Our more than 25,000 team members and more than 6,000 physicians aim to deliver transformative patient experiences and expert care close to home across more than 300 ambulatory locations and eight acute care hospitals - Edward (Naperville), Elmhurst, Evanston, Glenbrook (Glenview), Highland Park, Northwest Community (Arlington Heights) Skokie and Swedish (Chicago) - all recognized as Magnet hospitals for nursing excellence. For more information, visit www.endeavorhealth.org.
When you work for Endeavor Health, you will be part of an organization that encourages its employees to achieve career goals and maximize their professional potential.
Please explore our website (www.endeavorhealth.org) to better understand how Endeavor Health delivers on its mission to "help everyone in our communities be their best".
Endeavor Health is committed to working with and providing reasonable accommodation to individuals with disabilities. Please refer to the main career page for more information.
Diversity, equity and inclusion is at the core of who we are;... For full info follow application link.
EOE: Race/Color/Sex/Sexual Orientation/ Gender Identity/Religion/National Origin/Disability/Vets, VEVRRA Federal Contractor.
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