Clinical Documentation Specialist - Health Information Management

Reporting to the Clinical Documentation Coordinator facilitates improvement in the overall quality, completeness, and accuracy of medical documentation. Communicates with physicians, case managers, coders, and other health care team members to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all inpatients. Serves as a resource to all members of the health care team on documentation guidelines.

1. Facilitates appropriate documentation to ensure the level of services and acuity of care are accurately reflected in the medical record. Completes a review of the medical record for assigned patients reviewing and analyzing complications, co morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, and impact of procedures on DRG assignment. Educates health care team members and physicians on appropriate medical record documentation.

2. Collaborates with the medical staff and health team members to ensure accurate and complete documentation in the medical record. Maintains on-going face-to-face and written communications with physicians, interdisciplinary team members, and coding staff to clarify information, obtain additional documentation, and present opportunities to optimize comprehensive documentation. Follows up on responses to medical record queries to ensure accurate and complete documentation.

3. Educates all internal customers on compliance documentation responsibilities and coding and reimbursement issues. Develops physician education strategies to promote complete and accurate clinical documentation and correct negative trends in documentation. Confers with other clinical care providers to explain the importance of clear and concise documentation. Provides one on one education to physicians as appropriate.

4. Remains current with clinical knowledge and documentation requirements. Attends education programs that pertain to specialty area being covered. Assumes responsibility for professional development.

5. Adheres to all Northwest Community Hospital standards, policies, and procedures.

1. Nursing or HIM degree required. Bachelor’s degree preferred.

2. RN, RHIT, RHIA, CCS or CCDS required.

3. Current CPR certification for basic life support provider through the American Heart Association.

4. Minimum of five years of recent clinical nursing experience, inpatient coding or prior CDI experience required. Nursing experience in medical/surgical, critical care, or emergency care preferred.

5. Advanced communication and interpersonal skills to work with all levels of internal and external customers. Excellent written and verbal communication, critical thinking, and creative problem solving. Ability to be diplomatic and negotiate, with strong conflict management skills.

6. Proficient organization and planning skills necessary to work independently and effectively manage time.

7. Self directed with the ability to work in a fast paced environment.

8. Ability to project a professional image that is consistent with the NCH value of Customer Focus.

9. Strong computer skills and willingness to learn computer applications relative to position.

PHYSICAL REQUIREMENTS:
1. Requires light physical effort. May require frequent periods of standing or walking.
2. May require frequent lifting or moving of lightweight material, occasional moving or lifting of average weight materiel, rarely lifting or moving of heavy weight material.
3. The flow of work and the character of duties requires normal mental and visual attention much or all of the time.
WORKING CONDITIONS:
1. Conditions are acceptable. At least one disagreeable element or hazard (ie.infectious disease) is frequently present in the environment while several disagreeable elements or hazards are occasionally present.

About Northwest Community Healthcare

In January 2021, Northwest Community Healthcare (NCH) joined NorthShore University HealthSystem, which is now NorthShore – Edward-Elmhurst Health. The NCH Arlington Heights campus features a 509-bed hospital with a Level II Trauma Center, Level III Neonatal Intensive Care Unit and a dedicated pediatric acute care center. Throughout the northwest suburbs, NCH has 23 doctor’s offices; five immediate care centers; seven physical rehabilitation sites; and 13 lab locations.

NorthShore – Edward-Elmhurst 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. Located in Naperville, Linden Oaks Behavioral Health, provides for the mental health needs of area residents. For more information, visit NorthShore.org, SwedishCovenant.org, NCH.org and EEHealth.org.