Clinical Documentation Specialist RN Job at Advocate Aurora Health

Clinical Documentation Specialist-RN

This role will facilitate the modifications of clinical documentation through ex...

Location

United States , Chicago

Salary:

38.20 - 57.30 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Graduate from an accredited school of nursing
BSN
5 years relevant clinical experience (For associates in process level 25013 5 years relevant pediatric clinical experience)
Clinical documentation improvement experience preferred
Ability to prioritize work
Excellent communication skills
Good problem solving skills
Critical thinking skills
Basic Computer skills
Effective problem~solver with good interpersonal communication skills verbal and written

Job Responsibility

Facilitate the modifications of clinical documentation through extensive initial and concurrent interaction with physicians and other members of the healthcare team to support appropriate documentation of the clinical severity and risk of mortality is captured for the level of services rendered to select inpatients populations
Supports timely accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes and provides education to all members of the health care team on an ongoing basis
Improves the overall quality and completeness of clinical documentation by performing chart reviews using clinical documentation guidelines based on accepted standards evidenced based practice and current regulatory requirements
Educates all internal customers on clinical documentation opportunities

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program

Fulltime

Senior Specialist Education

Senior Specialist Education who excels in this role collaborates with nurse mana...

Location

United States , Martinsville

Salary:

Not provided

Copper Springs East

Expiration Date

Until further notice

Requirements

Current VA RN (or compact state) License
Graduate of a professional school of Nursing
Master's degree or currently enrolled in Master's in Nursing program required
Basic Life Support certification is required
Minimum two (2) years of clinical experience in an acute care hospital setting required
One (1) year of formal/informal teaching experience preferred
One (1) year of management experience preferred

Job Responsibility

Collaborates with nurse managers and staff to assess the learning needs and competencies of staff
Designs, delivers, and assesses learning activities and curriculums related to clinical competencies, departmental/organizational policies, regulatory requirements, and the use of clinical information technologies
Serves as a consultant/mentor for staff in areas of program development, clinical practice, and professional development
Participates in the development, coordination, and delivery of new staff orientation and education activities
Assists in development and implementation of educational programs/learning aids for clinical and non-clinical associates
Plans, coordinates, organizes, implements, and evaluates orientation programs, continuing education, and in-services that enhance associate job performance
Keeps appropriate educational records
Maintains A-V equipment, books, and educational supplies
Prepares schedules as needed for educational in-services and coordinates with persons involved
Conducts and assists others in orientation, in-services, continuing education, or workshops

What we offer

Multiple levels of medical, dental and vision coverage
Medical plans starting at just $10 per pay period
Tailored benefit options for part-time and PRN employees
Life, accident, critical illness, hospital indemnity insurance
Short- and long-term disability
Paid family leave
Paid time off
Higher education and certification tuition assistance
Loan assistance
401(k) retirement package and company match

Fulltime

Registered Nurse Clinical Documentation Integrity Specialist - Inpatient

Provides concurrent review of the clinical documentation in the medical record; ...

Location

United States , Tucson

Salary:

Not provided

Tucson Medical Center

Expiration Date

Until further notice

Requirements

Graduation from a qualified, nationally-accredited nursing program
Three (3) years of RN clinical experience in an acute care setting
Current RN licensure permitting work in state of Arizona
Extensive clinical knowledge and understanding of pathology/physiology
Strong critical thinking skills
Knowledge of age-specific patient needs and the elements of disease processes and related procedures
Excellent written and verbal communication skills
Assertive personality traits to facilitate ongoing physician communication
Working knowledge of inpatient admission criteria
Ability to work independently in a time-oriented environment

Job Responsibility

Provides concurrent review of the clinical documentation in the medical record
review the medical record with a clinical lens to identify any missing or understated diagnoses
Queries the medical staff when necessary, by written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan
Performs a thorough chart review to determine the appropriate principal diagnosis of the patient
Coordinates with coding/HIM/UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided
Conducts initial and follow-up concurrent reviews on inpatient admissions for opportunities to clarify documentation in the medical record for accurate reflection of the acuity of the patient and justifying the level of care
Documents findings in workflow tools, noting all key information used in the tracking process
Review medical record concurrently for documentation not yet in the record but supported by clinical indicators
Uses relationship building and strong communication skills to develop a rapport with providers to clarify information in the medical record
Uses appropriate querying templates to get needed documentation

Fulltime

Registered Nurse Clinical Documentation Integrity Specialist - Inpatient

Provides concurrent review of the clinical documentation in the medical record; ...

Location

United States , Tucson

Salary:

Not provided

Tucson Medical Center

Expiration Date

Until further notice

Requirements

Graduation from a qualified, nationally-accredited nursing program
Three (3) years of RN clinical experience in an acute care setting
Current RN licensure permitting work in state of Arizona
Extensive clinical knowledge and understanding of pathology/physiology
Strong critical thinking skills
Knowledge of age-specific patient needs and the elements of disease processes and related procedures
Excellent written and verbal communication skills
Assertive personality traits to facilitate ongoing physician communication
Working knowledge of inpatient admission criteria
Ability to work independently in a time-oriented environment

Job Responsibility

Provides concurrent review of the clinical documentation in the medical record
review the medical record with a clinical lens to identify any missing or understated diagnoses
Queries the medical staff when necessary, by written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan
Performs a thorough chart review to determine the appropriate principal diagnosis of the patient
Coordinates with coding/HIM/UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided
Conducts initial and follow-up concurrent reviews on inpatient admissions for opportunities to clarify documentation in the medical record for accurate reflection of the acuity of the patient and justifying the level of care
Documents findings in workflow tools, noting all key information used in the tracking process
Review medical record concurrently for documentation not yet in the record but supported by clinical indicators
Uses relationship building and strong communication skills to develop a rapport with providers to clarify information in the medical record
Uses appropriate querying templates to get needed documentation

Fulltime

Clinical Documentation Specialist

As a Clinical Documentation Integrity (CDI) Specialist, you will work under indi...

Location

United States , Centennial

Salary:

35.59 - 53.73 USD / Hour

American Nursing Care

Expiration Date

Until further notice

Requirements

Nursing Diploma or Associates Degree Required
Current RN license in state of employment or valid RN license from compact state, required
Three years of nursing experience in the inpatient hospital setting (critical care and/or strong med/surg experience preferred) or two years of nursing experience in the inpatient hospital setting and one year of CDI experience
Must demonstrate Clinical competency through successfully passing Clinical Competency exam through Nuance
Must demonstrate CDI software competency through passing Clintegrity exam within six months of starting role
Proficiency with MS Office software
Proficient in use of Electronic Health Record
Self-motivated with excellent interpersonal, critical thinking, analytical, organizational, and writing skills
Sedentary work -(prolonged periods of sitting and exert up to 10lbs force occasionally)

Job Responsibility

Facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient
Educate members of the patient care team regarding documentation guidelines and regulatory requirements, including attending physicians, allied health practitioners, nursing, and case management
Support timely, accurate, and complete documentation of clinical information used for measuring and reporting hospital and physician-based outcomes
Work independently majority of the time with a high degree of autonomy.

What we offer

Medical, prescription drug, dental, vision plans, life insurance, paid time off (full-time benefit eligible team members may receive a minimum of 14 paid time off days, including holidays annually), tuition reimbursement, retirement plan benefit(s) including, but not limited to, 401(k), 403(b), and other defined benefits offerings

Fulltime

New

RN Documentation Improvement Specialist

Location

United States , Kings Mountain

Salary:

38.20 - 57.30 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Registered Nurse applicable state Licensure required
Bachelor's Degree Required
Appropriate professional certification required within 3 years of hire date per department protocol
5 years of related nursing experience preferred
Clinical experience within the assigned population
Extensive knowledge of disease processes and clinical outcomes
Case Management experience or background helpful
Strong financial and analytical skills preferred
Word, Outlook, Excel experience preferred

Job Responsibility

Reviews selected populations of inpatient medical records to identify the principal and/or secondary diagnoses
Appropriately assigns the MS-DRG that most accurately reflects the severity of illness of the patient based upon the clinical evidence documented at the time of the record review
Demonstrates knowledge and understanding of severity based DRG systems
All Patient Refined and Medicare Severity (AP-DRG) and Medical Severity Diagnostic Related Group System (MS-DRG)
Demonstrates the ability to utilize the licensed software tool to perform and record daily medical record reviews
Interacts with the physician and/or other designated members of the healthcare team to ensure that vague or incomplete documentation is clarified within the medical record in a timely manner
Works with other departments such as coding, corporate compliance, quality, and finance to support Corporate Goals
Participates in the ongoing education of physicians, nurse practitioners, physician assistants and other healthcare team members to identify medical record documentation improvement opportunities employing conflict resolution skills as necessary
Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record
Ensures that all written requests to physicians for additional documentation support Corporate Compliance policies

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program

Fulltime

Nursing Education & Simulation Specialist

Collaborating with academic partners, faculty and staff, the Specialist provides...

Location

United States , Charlotte

Salary:

49199.00 - 86253.00 USD / Year

Adtalem Global Education

Expiration Date

Until further notice

Requirements

Bachelor's Degree in nursing Required
Master's Degree in Education Preferred or Master's Degree Nursing Preferred
1+ year experience in an academic environment supporting classroom instruction or specialized tutoring support Preferred
Excellent communication skills with proven ability to communicate via telephone, computer, and in person
Excellent analytical and problem-solving skills
Must have excellent attention to detail and proofreading skills
Ability to work with individuals from diverse cultural and professional backgrounds
Demonstrated working knowledge of Microsoft Office Suite (especially Word, Excel, PowerPoint and Outlook)
Must be a team player, willing to share and exchange
Maintenance of a current, unencumbered RN license Required

Job Responsibility

Facilitation of simulation-based experiences (SBE) and labs to include equipment maintenance, ordering supplies, set-up and clean-up
Demonstrates current, detailed, accurate knowledge of concepts tested by the NCLEX-RN as well as currency in nursing practice to provide academic support
Assists in the creation of Next Generation NCLEX activities/workshops
Demonstrates effective behaviors and accountability in meeting the following standards of service excellence to students, fellow team members, and external agencies: Friendliness and courtesy, professional environment, effective communication, and first-class service
Communicates and documents (reporting) students’ academic and co-curricular progress toward achievement of student and program learning outcomes to academic leadership (i.e., retention committee)
Assists in developing and implementing detailed clinically based scenarios for the simulated learning experiences, including use of high-fidelity patient simulators
Coordinates and supervises lab experiences to ensure that students have the opportunity to meet course objectives
Staffs open lab
Provides individual oversight to students during practice and/or remediation of technical nursing skills as required by course objectives
Individual or group tutoring

What we offer

Health, dental, vision, life and disability insurance
401k Retirement Program + 6% employer match
Participation in Adtalem’s Flexible Time Off (FTO) Policy
12 Paid Holidays

Fulltime

RN Documentation Improvement Specialist

RN Documentation Improvement Specialist position at Atrium Health Kings Mountain...

Location

United States , Kings Mountain

Salary:

38.20 - 57.30 USD / Hour

Advocate Health Care

Expiration Date

Until further notice

Requirements

Registered Nurse applicable state Licensure required
Bachelor's Degree Required
Appropriate professional certification required within 3 years of hire date per department protocol
5 years of related nursing experience preferred
Clinical experience within the assigned population
Extensive knowledge of disease processes and clinical outcomes
Case Management experience or background helpful
Strong financial and analytical skills preferred
Word, Outlook, Excel experience preferred

Job Responsibility

Reviews selected populations of inpatient medical records to identify the principal and/or secondary diagnoses
Appropriately assigns the MS-DRG that most accurately reflects the severity of illness of the patient based upon the clinical evidence documented at the time of the record review
Demonstrates knowledge and understanding of severity based DRG systems
All Patient Refined and Medicare Severity (AP-DRG) and Medical Severity Diagnostic Related Group System (MS-DRG)
Demonstrates the ability to utilize the licensed software tool to perform and record daily medical record reviews
Interacts with the physician and/or other designated members of the healthcare team to ensure that vague or incomplete documentation is clarified within the medical record in a timely manner
Works with other departments such as coding, corporate compliance, quality, and finance to support Corporate Goals
Participates in the ongoing education of physicians, nurse practitioners, physician assistants and other healthcare team members to identify medical record documentation improvement opportunities employing conflict resolution skills as necessary
Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record
Ensures that all written requests to physicians for additional documentation support Corporate Compliance policies

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program

Fulltime

Clinical Documentation Specialist RN

Advocate Aurora Health

Location:
United States

Category:
Nursing

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Nice to have:

Additional Information:

Job Posted:
February 20, 2026

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Location:United States

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Contract Type:Not provided

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Job Description:

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Requirements:

Nice to have:

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Job Posted:February 20, 2026

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Category:
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Contract Type:
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Job Posted:
February 20, 2026