Clinical Documentation Specialist

Pay range: $95,680 - $143,520 annually, based on experience. This exempt position comes with a comprehensive benefits package that includes medical, dental, vision, a 403(b) retirement plan, and a generous Earned Time Off (ETO) program.ST. CHARLES HEALTH SYSTEMJOB DESCRIPTIONTITLE:                                      Clinical Documentation Integrity Specialist IIREPORTS TO POSITION:       Manager, Clinical DocumentationDEPARTMENT:                         QualityDATE LAST REVIEWED:          April 2023OUR VISION:                            Creating America’s healthiest community, togetherOUR MISSION:                         In the spirit of love and compassion, better health, better care, better valueOUR VALUES:                          Accountability, Caring and TeamworkDEPARTMENT SUMMARY: The Clinical Documentation Department performs concurrent and selected retrospective medical record reviews in order to facilitate appropriate provider documentation that captures the most complete and accurate clinical conditions impacting patient visits. POSITION OVERVIEW: The Clinical Documentation Integrity Specialist II at St. Charles Health System provides clinical based review and analysis of the documentation in the patient’s medical record to support accurate capture of patient’s complexity and severity of illness. Utilizes queries of the medical staff and other caregivers to clarify and support completeness of documentation.This position does not directly manage any other Caregivers.ESSENTIAL FUNCTIONS AND DUTIES:Collaborates with physician, mid-level providers, ancillary staff, and medical records coders to identify principle and secondary diagnoses, and principle procedures. Also reviews for quality indicators.Maintains current knowledge of Medicare’s rules, regulations, and guidelines.Conducts initial and ongoing concurrent and some retrospective reviews for system wide admissions for all payors, initiates tracking process, and documents findings on EHR tracking system.Identifies when there is a need to clarify documentation in patient records and initiates queries or communication with providers to capture accurate documentation of the patient’s severity of illness and risk of mortality in compliance with all guid...