Clinical Documentation Specialist Jobs

Ann & Robert H. Lurie Children’s Hospital of Chicago provides superior pediatric care in a setting that offers the latest benefits and innovations in medical technology, research and family-friendly design. As the largest pediatric provider in the region with a 140-year legacy of excellence, kids and their families are at the center of all we do. Ann & Robert H. Lurie Children’s Hospital of Chicago is ranked in all 10 specialties by the U.S. News & World Report.

1. Completes initial reviews of patient records within 24 to 48 hours of admission. Collaborates with clinical staff to identify principal diagnosis options, secondary diagnoses and procedures, and to assign working DRGs for at least 85% of identified populations.
2. Utilizes inpatient admission criteria to assign only diagnoses that meet acute care criteria.
3. Conducts follow-up reviews of patients every 2 to 3 days. Identifies need to clarify documentation in records, and utilizes strong communication skills with clinical staff utilizing appropriate tools to capture needed documentation.
4. Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health records when needed.
5. Collaborates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation to resolve physician queries prior to patient discharge.
6. Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
7. Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identifies through daily and respective documentation reviews and aggregates data analysis.
8. Participates in analysis and trending of statistical data for specified patient populations to identify opportunities for improvement. Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership.
9. Partners with the coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, and/or risk of mortality.
10. Assists in the development of APR/DRG/query response physician reports.
11. Maintains complete confidentiality of patient information, in addition to hospital and individual physician practice pattern data.
12. Facilitates change processes required to capture needed documentation.
13. Assists in the appeal process resulting from third-party reviews.
14. Performs job functions adhering to service principles with customer service focus of innovation, service excellence and teamwork to provide the highest quality care and service to our patients, families, co-workers and others.
Knowledg/Skills/Abilities
1. Bachelor's degree in nursing with current license required with minimum of 5 years of acute care nursing, pediatric experience preferred.
2. Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes strongly preferred.
3. Ability to communicate with all levels of clinical staff.
4. Demonstrated understanding and ability to recognize complex diagnoses, clinical complications and co-morbidities.
5. Ability to work independently in a time-oriented environment.
6. Excellent written and verbal communications skills as well as critical thinking skills.
7. Working knowledge of reimbursement systems and coding structures preferred.

Education

Benefit Statement

For full time and part time employees who work 20 or more hours per week we offer a generous benefits package that includes:

Medical, dental and vision insurance

Employer paid group term life and disability

Employer contribution toward Health Savings Account

Flexible Spending Accounts

Paid Time Off (PTO), Paid Holidays and Paid Parental Leave

403(b) with a 5% employer match

Various voluntary benefits:

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