Clinical Documentation Specialist - Illinois

Job Summary

To enhance clinical documentation accuracy, the full-time Clinical Documentation Specialist - Illinois will perform concurrent analytical reviews of clinical and coding data, educate healthcare providers, and collaborate with coding professionals in a remote work environment.

Key responsibilities

• Completes initial and follow-up reviews of patient records to assign diagnoses and procedures for accurate DRG assignments
• Queries physicians for clarification on documentation and educates the healthcare team on documentation improvement
• Collaborates with coding professionals to resolve discrepancies and ensure accurate DRG and SOI assignments

Required qualifications

• Graduate of an accredited nursing program, PA, NP, or medical school, or an Associate's degree with CCDS certification
• Two years of experience in an acute care setting or relevant experience
• Certification as a Clinical Documentation Specialist (CCDS) or relevant medical licensure in the state of Illinois
• Understanding of coding guidelines, regulatory policies, and healthcare economics
• Ability to conduct independent research on clinical topics and documentation standards