Clinical Documentation Specialist RN- Full Time

Reporting to the Director of Coding, Chicago Market is responsible for improving the overall quality and completeness of clinical documentation. Performs concurrent record reviews on all selected admissions and document findings. Facilitates modifications to clinical documentation to accurately reflect patient severity of illness and risk of mortality through extensive interaction with physicians, case management, nursing staff, other patient care givers and medical records coding staff.


  1. Initiates and performs concurrent documentation review of selected inpatient records to clarify conditions/diagnoses and procedures where inadequate or conflicting documentation is suspected.

  2. Communicates with the individual physician or medical staff departments to facilitate complete and accurate documentation of the inpatient record.

  3. Serves as a resource for physicians to help link ICD-9-CM coding guidelines and medical terminology to improve accuracy of patient severity of illness, risk of mortality and final code assignment.

  4. Works in a collaborative fashion with the Coders and Case Managers concurrently reviewing the inpatient medical record to assure correct provisional and final Diagnosis Related Group (DRG) assignment.

  5. Monitors and evaluates the effectiveness of concurrent chart review and query outcomes at designated intervals. Maintains accurate records of review activities to comply with departmental and regulatory agency guidelines.

  6. Ensures for the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.

  7. Reports concurrent chart review and query outcomes to hospital departments and committees at designated intervals.

  8. Performs monthly closed chart reviews and serves on the Chart Documentation Committee.


Current licensure as a Registered Nurse in the State of Illinois.

Two (2) years of experience in an acute care setting.

Knowledge of care delivery documentation systems and related medical records documents.

Strong broad-based clinical knowledge and understanding of the pathology/physiology of disease processes.

Level of knowledge normally acquired through the completion of a Bachelor's Degree in Nursing.

Excellent written and verbal communication skills, critical thinking skills and interpersonal skills necessary to build effective partnering relationships with physicians, the case management team, nursing staff, coding staff and the hospital staff.

Proficient in Microsoft Office applications and familiar with basic office equipment.

Ability to work independently in a time oriented environment.

Self directed, motivated and possess a positive attitude.

Medical Coding

Primary Location:
Oak Park, Illinois

West Suburban Medical Center

Job Type:

Shift Type:

Employment practices will not be influenced or affected by an applicant's or employee's race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.


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