RN Clinical Documentation Specialist

Hourly Pay Range

$38.67 - $59.94 - The hourly pay rate offered is determined by a candidate's expertise and years of experience, among other factors.

Position Highlights

Position : Clinical Documentation Specialist

Location : Elmhurst, IL

Full Time / Part Time : Full time

Hours : Monday-Friday, [hours and flexible work schedules]

Position Summary

The Clinical Documentation (CDI) Specialist is responsible for improving the overall quality and completeness of clinical documentation to ensure accurate coding, appropriate reimbursement, and compliance with regulatory requirements. This role involves working closely with physicians, healthcare providers, and coding staff to clarify and enhance the documentation of clinical information.

What You Will Do

Review medical records concurrently to ensure accuracy, completeness, and specificity of clinical documentation. Identify and clarify missing, conflicting, or nonspecific physicians’ documentation through queries and follow up. Collaborate with healthcare providers to ensure accurate and comprehensive documentation of patient diagnoses and treatments.

Develop and implement effective query to resolve documentation issues. Ensure queries are clear, concise, and compliant with industry’s standards and regulatory requirements. Track and follow up on outstanding queries to ensure timely responses. Query format and questions meet AHIMA and ACIDS guideline. Ensures adherence to professional standards, quality standards, licensure, and federal laws.

Ensure clinical documentation complies with all applicable regulations and standards, including those set by CMS, Joint Commission, and other governing bodies.

Provide education to the physicians and other clinical staff on documentation best practice and importance of accurate clinical documentation.

Attend education programs, workshops, and one-one-one training to enhance continuous learning. Participate in professional organization such as the Clinical Documentation Improvement Specialist (ACDIS) or the American Health Information Management. Actively engage in mentoring relationships to support less experienced colleagues and contribute to professional development within the team.

May include but not limited to special projects related to Revenue Cycle or Endeavor System workflow, process improvement or task forces

What You Will Need

Education : Associate in Nursing or HIM is required

Experience : 3-5 years RN experience Acute Care Hospital (critical care preferred)

License / Certifications : Registered Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR) Required

Benefits

Career Pathways to Promote Professional Growth and Development

Various Medical, Dental, and Vision options

Tuition Reimbursement

Free Parking at designated locations

Wellness Program Savings Plan

Health Savings Account Options

Retirement Options with Company Match

Paid Time Off

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; being there for our patients and each other with compassion, respect and empathy. We believe that our strength resides in our differences and in connecting our best to provide community-connected healthcare for all.

EOE : Race / Color / Sex / Sexual Orientation / Gender Identity / Religion / National Origin / Disability / Vets, VEVRRA Federal Contractor.