Clinical Documentation Spec-RN

Major Responsibilities:

• Improves the overall quality and completeness of clinical documentation by performing chart reviews using clinical documentation guidelines based on accepted standards, evidenced based practice, and current regulatory requirements.
• Educates all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement strategies.
• Maintains the integrity of data bases, tracks and trends response to clinical documentation and measures for performance improvement.
• Demonstrate positive and effective interpersonal relations dealing with all members of the team (ie co-workers, physicians, leadership, etc.).

Licensure:

• Nurse, Registered (RN)

Education/Experience Required:

• Graduate from an accredited school of nursing BSN 5 years relevant clinical experience, Clinical documentation improvement experience preferred

Knowledge, Skills & Abilities Required:

• Ability to prioritize work Excellent communication skills Good problem solving skills Critical thinking skills Basic Computer skills Effective problem-solver with good interpersonal communication skills, verbal and written Effective observation, analytical, and critical thinking skills
• Current nursing license in the State of Illinois. Certification in clinical documentation improvement preferred.

Physicial Requirements and Working Conditions:

• Ability to work in changing environment Ability to prioritize independently and respond to multiple simultaneous requests Ability to work under stressful conditions and in difficult situations May be exposed to hazardous materials and life threatening diseases This position needs to recognize needs and behaviors of specific age groups of patients treated. Extensive knowledge and experience of ICD-10 coding classification system and DRGs
• none

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.