Clinical Documentation Specialist - Illinois

Job Summary

Clinical Documentation Specialist - Illinois, is a full-time position responsible for auditing and improving clinical documentation to ensure it accurately reflects patient health status and meets regulatory requirements.

Key Responsibilities

• Review clinical records for documentation integrity and mortality scoring
• Collaborate with clinical staff to improve documentation and risk adjustment findings
• Maintain knowledge of CMS requirements and provide feedback during concurrent record reviews

Required Qualifications

• Graduate of an accredited nursing school, PA, NP, or medical school, or Associate's degree with CCDS certification
• Two years of experience in an acute care setting with clinical documentation, or four years of clinical documentation experience with CCDS certification
• Certification as a Clinical Documentation Specialist (CCDS) or relevant medical licensure in Illinois
• Ability to work in a fast-paced environment and manage multiple tasks
• Knowledge of mortality models and clinical documentation improvement practices