Rush University Medical Center  Clinical Documentation Specialist RN 2 in Chicago, Illinois

Job Title: Clinical Documentation Specialist RN 2

Department: Case Management

Shift: 1st

Full/Part: Active Regular FT (72 to 80 hours per pay period)


Job Number: 2018-3580

Job Description:

Clinical Documentation Specialist RN 2

Rush University Medical Center presents an exciting opportunity for a Clinical Documentation Specialist RN 2 in Care Management. The Clinical Documentation Specialist 2 (CDS) demonstrates expert knowledge of documentation principles and is responsible for improving the overall quality and completeness of clinical documentation. The CDS facilitates modifications to clinical documentation through interaction with physicians, nursing staff, other patient care givers, and Health Information management coding staff to ensure that documentation accurately reflects each patient’s severity of illness. The CDS participates in the monitoring of quality indicators and ensures accuracy and completeness of clinical information used for measuring and reporting physician and Rush outcomes, and educates all members of the patient care team on an ongoing basis. The individual who holds this position exemplifies the Rush mission, vision, and values and acts in accordance with Rush policies and procedures

Position Responsibilities:

  • Demonstrates expert knowledge of DRG payer issues, documentation requirements and strategies, and policies and procedures.

  • Serves as a consultant and resource for others.

  • Improves the overall quality and completeness of clinical documentation by performing initial and continued stay reviews using clinical documentation guidelines. Queries and facilitates modifications to clinical documentation to ensure that documentation accurately reflects each patient’s severity of illness and risk of mortality.

  • Participates in the monitoring of quality indicators.

  • Provides ongoing communication with coders, auditors, case managers, nurses, and physicians to ensure that documentation reflects the care and services provided.

  • Documents actions in the CDI software including queries and responses.

  • Conducts follow-up reviews of clinical documentation to ensure points of clarification with physicians have been recorded in the patient’s chart.

  • Processes discharges by updating the appropriate 3M 360 screens to reflect any changes in status, procedures/treatments, and conferring with physicians to finalize diagnoses. Assists HIM in resolving post discharge queries.

  • Demonstrates expert clinical expertise, skills, and behaviors appropriate to the populations served, based on specific criteria and/or age-specific considerations.

  • Supports the screening and referral process and maintains open communication with certification staff, finance, case managers, HIM staff, and providers to ensure quality and continuity of patient care.

  • Serves as a resource and educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.

  • Develops and conducts ongoing clinical documentation improvement education for new staff, including new case managers, coders, physicians, residents, nursing, and allied health professionals.

Position Qualifications Include:

  • Current State of Illinois RN licensure required.

  • Bachelor’s degree in Nursing required.

  • A minimum of three years of inpatient coding or clinical nursing experience with medical/surgical care management expertise.

  • Coding knowledge and/or clinical documentation improvement program experience is required.

  • Certification in clinical documentation improvement required (or willingness to obtain within 1 year).

  • Excellent interpersonal and communication skills.

  • Ability to work collaboratively with all members of the healthcare team.

  • Computer skills and willingness to learn CDI software.

Company Highlights:

  • Ranked among the top academic medical centers in the country, Rush University Medical Center is an outstanding place to enhance your career. Everything we do centers on one goal: improving patient care.

  • Rush is an academic health system comprising Rush University Medical Center, Rush Copley Medical Center and Rush Oak Park Hospital.

  • Rush University Medical Center is a four-time Magnet® facility, the highest recognition given for nursing excellence. Rush was also the first hospital in Illinois serving adults and children to receive Magnet status.

  • Ranked among the top 20 best places to work in healthcare by Indeed.

  • Rush was ranked Best Hospital in Illinois for Nurses in 2017 by

  • Rush offers a competitive salary, and valuable healthy living benefits including: health, dental and vision to help you maintain and improve your health. Rush also offers several ways to invest in your future.

Rush is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, and other legally protected characteristics.