RN Specialist at Advocate Health ensuring accurate clinical documentation and coding compliance. Collaborating with healthcare teams to improve patient record quality and completeness.
About the role
- Clinical Documentation Specialist at OhioHealth reviewing inpatient medical records for severity of illness and risk of mortality. Collaborating with providers to enhance clinical documentation accuracy in a supportive environment.
Responsibilities
- Reviews inpatient medical records and identifies potential opportunities in provider documentation to accurately reflect severity of illness (SOI) and risk of mortality (ROM)
- Communicates with provider or designee to request clarification or additional documentation
- Exhibits expert knowledge of clinical documentation requirements, coding guidelines, DRG assignment, and clinical conditions
- Collaborates with the Health Information Management Department coding staff regarding clinical documentation
- Assists with implementing plans for both formal and informal education of providers and other departments
Requirements
- Bachelor's Degree (Required)
- RN - Registered Nurse - Ohio Board of Nursing
- Minimum 5 years Experience in adult inpatient medical/surgical or critical care setting
- Certification in health-related field or Clinical Documentation Improvement
- Strong critical thinking and clinical expertise
- Organization and computer skills.
Benefits
- Health insurance
- Flexible work arrangements
- Professional development opportunities
Job title
Job type
Experience level
Salary
Not specified
Degree requirement
Location requirements
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