Clinical Information System Specialist jobs in Wheaton, IL

GENERAL SUMMARY:

Reporting to the Director of HIM, CDI and Coding, 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 and mid-level providers, case management, nursing staff, other patient care givers and coding staff. 

PRINCIPAL DUTIES AND RESPONSIBILITIES:

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.      Partners with operational and medical leadership in a given service line to identify, develop and implement successful communication and education, to engage physicians and improve processes and outcomes.

4.      Rounds daily with physician and mid-level providers to ensure appropriate and accurate documentation in the medical record.

5.      Ensures the level of services and acuity of care will accurately be reflected in quality outcomes.

6.      Performs data collection activities to identify documentation issues, quality issues and opportunities for improvement in patient care and services.

7.      Analyzes quality and patient safety data to identify patterns in the management of patient care and services using reported 1.) Hospital acquired conditions, 2.) Patient safety indicators, 3.) Case Mix Index, and 4.) Expected mortality.