RN – Clinical Documentation Integrity Specialist

🔥 13 hours ago

🌽 Illinois – Remote

🌽 Illinois – Remote

💵 $34 - $59 / hour

⏱ Part Time

🟢 Junior

🟡 Mid-level

🏥📝 Medical Writer

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Carle Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1946

⚕️ Healthcare Insurance

🏥 Healthcare

📚 Education

Healthcare Insurance • Healthcare • Education

Carle Health is a comprehensive healthcare provider dedicated to managing the health needs of its community. Offering a wide range of services, from general medical care to specialized treatments in oncology, cardiovascular, pediatrics, and women's health, Carle Health emphasizes quality patient care and community health initiatives. Additionally, it supports education and research through the Carle Illinois College of Medicine and engages in community health programs that aim to improve overall well-being.

📋 Description

• Perform inpatient chart reviews to determine appropriate DRG assignments • Ensure medical record documentation supports clinical care, severity of illness, risk of mortality, Case Mix Index, and mortality ratings • Clarify documentation with physicians, nurses, and ancillary staff • Document findings in Carle CDI software and update encounter status • Coordinate with physicians, nurses, ancillary hospital staff, and Health Information Management coding staff • Identify and record principal and secondary diagnoses and procedures • Assign working DRGs and perform second-level reviews of selected inpatient encounters • Follow the query process and escalate as necessary • Provide CDI education to peers and providers • Review DRG denials and develop appeal letters when needed • Attend mandatory and regular education sessions • Follow workflows in EPIC and CDI software and report issues to the one-up leader • Participate in testing software upgrades as needed

🎯 Requirements

• Must have 2 years of working Clinical Documentation experience • Must have 2 years of Nursing or MD experience • Registered Health Information Administrator (RHIA) certification, or Licensed Registered Professional Nurse (RN) within 6 months if licensed in another state • Illinois RN licensure through the Illinois Department of Financial and Professional Regulation (IDFPR), if applicable • Associate's Degree in Nursing, Associate's Degree in Health Information Management, or Doctorate degree in Medicine • 2 years CDI experience • 2 years clinical bedside experience • Ability to work occasional weekends • Ability to work the M-F 8a-5p day schedule

🏖️ Benefits

• Comprehensive benefits package • Equal opportunity employment • Potential for growth and life-long careers