Ambulatory RN Clinical Documentation Integrity Specialist
Ambulatory RN Clinical Documentation Integrity Specialist
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Job Description
Position Highlights:
- Position: Ambulatory RN Clinical Documentation Integrity Specialist
- Hourly Pay Range: $35.16-$54.50/hour. The hourly pay rate offered is determined by a candidates expertise and years of experience among other factors.
- Location: Skokie IL
- Full Time/Part Time: Full time
- Hours: Monday-Friday standard business hours 8am-4:30pm
Position Summary:
The Ambulatory Clinical Documentation Integrity Specialist (CDS) is a clinical position using clinical/nursing knowledge and understanding of national coding guidelines and standards of compliance to improve overall quality and completeness of clinical documentation within the patient electronic health record (EHR) using a multidisciplinary team process. Works collaboratively with ambulatory physicians advance practice providers and HCC coding specialists to ensure the clinical information within the EHR is accurate complete and compliant. This includes accurate documentation to support the capture of Hierarchical Condition Categories (HCC) ICD-10-CM specificity and medical necessity of ambulatory visits. Compliantly queries the provider as needed in their prospective chart reviews to ensure specification and clarification of documentation is captured at the time of the patients addition the CDS educates members of the patient care team both formally and informally regarding documentation guidelines coding requirements and service specific requirements.
What you will do:
- Partners with operational and physician advisors to identify develop and implement successful communication and education to engage providers and improve outcomes processes and support HCC capture of ambulatory visits
- Performs daily medical record reviews and data collection activities to identify documentation issues quality issues and opportunities for improvement
- Ensures level of service and acuity of care is accurately reflected in quality outcomes
- Demonstrates knowledge of documentation requirements and coding guidelines that pertain to ambulatory diagnosis coding to accurately reflect the complexity and medical necessity of the visit.
- Monitors assists and tracks the progress of the program through analysis trending and presentation of audit/review findings potential issues and their root cause. Serves as a resource to physicians and administration regarding issues related to compliant documentation.
Educates Physicians and Staff regarding the need for accurate specific and complete clinical documentation in the patients medical record.
- Collaborates with Physicians Advanced Practice Providers Ambulatory CDI Staff and HIM/Ambulatory Coders as well as works directly with individuals and departments where documentation improvement opportunities exist.
- Demonstrates responsibility and accountability for personal development by participating in continuing education offerings and maintaining credentials required for role.
- Utilizes software systems to collect and ensure the effectiveness of the data. Maintains the integrity of data collection by ensuring accurate data entry and demonstrates competence in navigation of software.
- Applies knowledge of professional nursing standards best practices and interdisciplinary collaboration to advance problem analysis and resolution and creative process redesign.
- Assists the coding team leads with onboarding new coding specialists to the role as needed.
- Excellent communication skills (verbal and written) to enable effective outcomes with diverse complex clinical care teams
- Consistently maintains a minimum 95% accuracy on documentation quality audits
- Meet minimum productivity requirements as outlined by the project terms
What you will need:
- Education: Associate degree in nursing (ADN) required
- Experience: Minimum 3 years clinical experience within an inpatient or ambulatory setting
- Certification: CRC or CCDS preferred. CRC will be required to obtain a professional coding certification within six months of hire
Benefits (For full time or part time positions):
- Career Pathways to Promote Professional Growth and Development
- Various Medical Dental Pet and Vision options
- Tuition Reimbursement
- Free Parking
- Wellness Program Savings Plan
- Health Savings Account Options
- Retirement Options with Company Match
- Paid Time Off and Holiday Pay
- 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 25000 team members and more than 6000 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 .
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 () 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.
Required Experience:
Unclear Seniority
Employment Type
Full-Time
