- Position Summary: Consistent with the mission, philosophy, and policies of Loyola University Health System, the Clinical Documentation Specialist (CDS) demonstrates clinical nurse leadership, project management skills, and the accountability to prompt physicians and advance practice nurses to provide details and clarity in documentation necessary for accurate medical record coding and billing. The CDS facilitates accurate documentation for severity of illness and quality in the medical record. Works closely with HIM coding staff to facilitate accurate documentation of discharge diagnosis and co-existing co-morbidities. Recognizes and consistently applies knowledge of Loyola's 14 Magnet Forces.
Required: Bachelors Degree OR equivalent training acquired via work experience or education
Preferred: Bachelors Degree
Required: 3-5 years of previous job-related experience
Preferred: 6-10 years of previous job-related experience
Minimum Experience Details: Previous Clinical Documentation or Case Management experience desirable.
Required: Current Registered Nurse License State of Illinois
Preferred: Emergency Medical Technician (NR-EMT-P)
Position Responsibilities: Medical Record Review: Reviews inpatient medical records as directed on admission and throughout hospitalization for completeness and accuracy for severity of illness (SOI) and quality. Communication: Effective and appropriate communication with attending physicians, residents, fellows and APNs either verbally or through written methodology to validate observations and suggest additional and/or more specific documentation. Education: Acts as a resource person for the interdisciplinary team in order to promote collaboration and coordination of patient care, considering age specific, developmental, cultural and spiritual needs of the patient. Quality: Consistently meets established productivity targets for record review with optimal performance at 20 charts/day, comprised of a mixture of initial chart reviews within 24 hours or admission and re-reviews. Medical Records Coding: Works closely with HIM coding staff to assure documentation of discharge diagnosis (es) and any co-existing co-morbidities are a complete reflection of the patient's clinical status and care. Professional Development: Establish effective networks with colleagues inside and outside Loyola.