Clinical Documentation Specialist

Responsibilities

• Facilitate improvements in the quality and completeness of inpatient medical record documentation on a concurrent basis.
• Communicate with attending physicians verbally and in writing to validate observations and clarify ambiguous documentation.
• Ensure accurate depiction of clinical services and patient severity of illness in accordance with ICD-10 CM guidelines.
• Collaborate with physician leadership to design and implement tools that support documentation requirements.
• Provide formal and informal education to the care team regarding clinical documentation standards.
• Maintain strict patient and hospital confidentiality in all communications.

Requirements

• Bachelor's Degree.
• Active Illinois RN License.
• Strong analytic skills to clinically assess medical records.
• Excellent interpersonal skills for effective physician communication.
• Basic computer proficiency in word processing and spreadsheet software.

Preferred Qualifications

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

About the Company

UChicago Medicine is a world-class academic healthcare system at the forefront of medical innovation. We provide superior healthcare with compassion, serving the health needs of our community while advancing medical knowledge. Join us in doing work that truly matters.