• Completes initial reviews of inpatient health records within 24-48 hours of admission and outpatient health records for a specified patient population to evaluate documentation to assign the principal diagnosis and pertinent secondary diagnoses for severity of illness and risk of mortality
• Queries physicians regarding missing under or conflicting health record documentation and obtains additional documentation within the health record when needed
• Conducts follow-up reviews of patients every 2-3 days to support documentation adequacy upon patient discharge as necessary
• Follows clients Clinical Documentation Program Guidelines in carrying out position functions; works accurately within the hospitals designated clinical documentation system
• Educates physicians and key healthcare providers regarding clinical documentation Improvement and the need for accurate and complete documentation in the health record
• Demonstrates an understanding of medical necessity severity of Illness complications comorbidities risk of mortality case mix secondary diagnoses and procedures and is able to impart this knowledge to physicians and other members of the interdisciplinary healthcare team
• Collaborates with the physician advisor case managers nursing staff and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge
• Participates in the analysis interpretation and trending of statistical data for specified patient populations to identify opportunities for clinical documentation and process Improvement
• Assists with preparation and presentation of clinical documentation monitoring and trending reports for review with physicians and hospital leadership
• Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues Identified through daily and retrospective documentation reviews and aggregate data analysis
• Facilitates change processes required to capture needed documentation such as forms and screen design
• Partners with the coding professionals to ensure adequate coding understanding to support clinical documentation necessary to determine a working severity of illness
• Reviews and clarifies clinical issues In the health record With the coding professionals that would support accurate and specific diagnoses and procedural coding
• Assists in appeal process resulting from third-party reviews
• Performs other duties as assigned

• Valid license as a Registered Professional Nurse in the State of Illinois OR a Registered Health Information Technician (RHIT) OR a Registered Health Information Administrator (RHIA)
• Three (3) years of experience in acute care nursing as a registered health information technician or as a registered health information administrator OR a combination of the three totaling three (3) years of experience
• One (1) year of experience within the last five (5) years working in Clinical Documentation Improvement
• One (1) year of experience working with Case Mix ICD 10 coding principal and secondary diagnoses procedures complications comorbidities severity and patient mortality risk
• Current experience with federal state and other payers regulatory requirements and criteria including but not limited to Medicare and Medicaid
• Prior experience working in a hospital or health care environment
• Must be detail oriented for clinical documentation review
• Must be familiar with electronic health record systems i.e. Cerner or Siemens

• Five (5) years of acute care nursing experience or as a registered health information administrator
• Two (2) years of experience within in the last three (3) years working in Clinical Documentation Improvement
• Two (2) years of experience working with Case Mix ICD 10 coding principal and secondary diagnoses procedures complications comorbidities severity and patient mortality risk
• Two (2) years of experience with federal state and other payers regulatory requirements and criteria including but not limited to Medicare and Medicaid
• Current experience with lnterQual and/or Milliman Care guidelines
• Certified Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS)

• Certified Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS)
• Knowledge and application of AHIMA and/or ACDIS Ethical Standards
• Knowledge of but not limited to current CMS coding guidelines and methodologies MS DRGs APR-DRGs HCCs; ICD-10-CM/PCS and AMA CPT coding guidelines and conventions
• Interpersonal verbal written communication skills in dealing with inter and intradepartmental activities
• Critical thinking skills with the ability to assess evaluate and teachOrganizational and analytical thinking skills
• Ability to develop and maintain supportive collaborative relationships with Physicians and other clinical professional
• Ability to provide concise reports of activities and results
• Ability to work independently in performing duties with minimal supervision with a high degree of self-motivation
• Ability to teach in a large group setting to educate healthcare providers about current documentation standards
• Ability to track activities and communication across multiple physician services and forums
• Ability to work with clinical manager case management and physicians to make clinical documentation improvements i.e. change clinical documentation processes
• Ability to analyze problems and issues and understand the regulatory andreimbursement impact of those decisions
• Ability to become adaptable and self-motivated by staying abreast of CMS rules and regulations and incorporating those changes into daily practice
• Proficiency in Microsoft Office Suite (Word Excel and PowerPoint)

Compensation Package:

• Competitive Salary
• Paid Time Off
• Health Vision & Dental Insurance
• Health Savings Account (HSA)
• Flexible Spending Account (FSA)
• Short & Long Term Disability
• 401 (K) with company match
• Life Insurance