Clinical Documentation Specialist

Be a part of a world-class academic healthcare system at UChicago Medicine as a Clinical Documentation Specialist for the Medical Records Department. This position is hybrid and requires travel to our Hyde Park Campus in Chicago IL as needed.

The Clinical Documentation Specialist is responsible for facilitating improvement in the overall quality and completeness of medical record documentation on a concurrent this role the Clinical Documentation Specialist - Inpatient promotes modifications to medical record documentation to ensure accurate depiction of the level of clinical services provided to the patient and to completely describe patients severity of illness. The CDS obtains appropriate clinical documentation through collaborative communications from having developed positive working relationships with physicians nursing staff other patient care providers and the Health Information Management Department Coders. The CDS is also responsible for providing informal and formal education to all members of the care team regarding clinical documentation.

Essential Job Functions

• Communicates with attending physician(s) verbally and through written methodology to validate observations and obtain clarification of incomplete unclear and ambiguous documentation including clarification of POA.
• Demonstrates and applies basic knowledge of documentation requirements and guidelines in accordance with ICD-10 CM Official Guidelines for Coding and Reporting.
• Consistently meets established productivity targets for record review.
• In collaboration with physician leadership designs and implements specific tools to support physician documentation requirements.
• Maintains the confidentiality of information acquired pertaining to patients physicians associates and visitors.
• Discusses patient and hospital information only among appropriate personnel in private and appropriate settings.
• Assumes responsibility for performance of job duties in the safest possible manner to assure personal safety and that of co-workers and to report all preventable hazards and unsafe practices immediately to management.

Required Qualifications

• Analytic skills necessary to clinically assess medical records
• Bachelors Degree
• IL RN License
• Basic computer skills in word processing and spreadsheet utilization
• Excellent interpersonal skills necessary to develop and foster effective physician communication

Preferred Qualifications

• 5-8 years experience in Case Management or Med/Surg or Critical Care nursing experience
• Masters Degree
• CCS coding credential

Position Details

• Job Type/FTE: Full Time (1.0 FTE)
• Shift: Days 8-hour shift
• Job Location: Hyde Park (Chicago IL)
• Unit/Department: Medical Records
• CBA Code: Non-Union

Weve been at the forefront of medicine since 1899. We provide superior healthcare with compassion always mindful that each patient is a person an individual. To accomplish this we need employees with passion talent and commitment with patients and with each other. Were in this together: working to advance medical innovation serve the health needs of the community and move our collective knowledge forward. If youd like to add enriching human life to your profile UChicago Medicine is for you. Here at the forefront were doing work that really matters. Join us. Bring your passion.

UChicago Medicine is growing; discover how you can be a part of this pursuit of excellence at:UChicago Medicine Career Opportunities.

UChicago Medicine is an equal opportunity employer. We evaluate qualified applicants without regard to race color ethnicity ancestry sex sexual orientation gender identity marital status civil union status parental status religion national origin age disability veteran status and other legally protected characteristics.

Must comply with UChicago Medicines COVID-19 Vaccination requirement as a condition of employment. If you have already received the vaccination you must provide proof as part of the pre-employment process. This is in addition to your compliance with the Flu Vaccination requirement as well. Medical and religious exemptions will be considered consistent with applicable law. Lastly a pre-employment physical drug screening and background check are also required for all employees prior to hire.

Compensation & Benefits Overview

UChicago Medicine is committed to transparency in compensation and benefits. The pay range provided reflects the anticipated wage or salary reasonably expected to be offered for the position.

The pay range is based on a full-time equivalent (1.0 FTE) and is reflective of current market data reviewed on an annual basis. Compensation offered at the time of hire will vary based on candidate qualifications and experience and organizational considerations such as internal equity. Pay ranges for employees subject to Collective Bargaining Agreements are negotiated by the medical center and their respective union.

Review the full complement of benefit options for eligible roles at Benefits - UChicago Medicine.