**Job Description** **Location:** Chicago, Illinois **Business Unit:** **Hospital:** Rush University Medical Center **Department :** CM- CDI Clinical Documentation Integrity **Work Type:** Full Time (Total FTE between 0.9 and 1.0) **Shift:** Shift 1 **Work Schedule:** 8 Hr (7:00:00 AM - 3:00:00 PM) Rush offers exceptional rewards and benefits learn more at our Rush benefits page (https://www.rush.edu/rush-careers/employee-benefits). **Pay Range:** $40.78 - $70.65 per hour Rush salaries are determined by many factors including, but not limited to, education, job-related experience and skills, as well as internal equity and industry specific market data. The pay range for each role reflects Rush’s anticipated wage or salary reasonably expected to be offered for the position. Offers may vary depending on the circumstances of each case. **Summary:** The Clinical Documentation Specialist II Registered Nurse (CDS II RN) demonstrates expert knowledge of documentation principles and is responsible for improving the overall quality and completeness of clinical documentation. The CDS facilitates modifications to clinical documentation through intensive interaction with providers (physicians/APPs), nursing staff, other patient care givers, and Health Information Management (HIM) coding staff to ensure that documentation accurately reflects each patient’s severity of illness, risk of mortality, and the quality of care provided. Participates in the monitoring of quality indicators. In addition, the CDS II RN ensures accuracy and completeness of clinical information used for measuring and reporting provider and Rush outcomes, and educates all members of the patient care team on an ongoing basis. Exemplifies the Rush mission, vision and values and acts in accordance with Rush policies and procedures. **Other information:** **Required Job Qualifications:** • State licensed RN and BSN. • 5 years inpatient or clinical nursing experience with medical/surgical care, ICU or ED management experience. • 2 years of clinical documentation Integrity experience required • Certification in clinical documentation integrity or commit to obtain with in 1 year • Demonstrated critical thinking skills. • Demonstrated expert knowledge of DRG payer issues, documentation requirements and strategies, as well as policies and procedures. • Coding knowledge and/or clinical documentation integrity program experience is required. • Advanced knowledge of inpatient ICD-10-CM and PCS guidelines. • Knowledge of medical terminology, classifications systems and vocabularies. • Knowledge of privacy and security regulations, confidentiality, and access and release of information practices. • Excellent interpersonal communication skills, ability to work independently and collaboratively with all members of the health care team. • Computer skills and the willingness to learn CDI software is required **Disclaimer:** The above is intended to describe the general content of and requirements for the performance of this job. It is not to be construed as an exhaustive statement of duties, responsibilities or requirements. **Responsibilities:** 1.• Improves the overall quality and completeness of clinical documentation by independently performing initial and continued stay reviews using Rush clinical documentation guidelines. • Queries and facilitates modifications to clinical documentation to ensure that documentation accurately reflects each patient’s severity of illness, risk of mortality, and quality of care provided. • Participates in the monitoring of quality indicators. • Provides ongoing communication with coders, auditors, care managers, nurses, and providers to assure that documentation reflects the care and services provided. • Documents actions in the CDI software (3M 360, Epic CDI, and Iodine) including queries and responses. • Assists HIM in resolving post discharge queries. • Educates internal customers on clinical documentation integrity principles, possible documentation opportunities, coding and reimbursement issues. • Develops and conducts ongoing clinical documentation integrity improvement education for new staff, including new CDS, care managers, coders, physicians, residents, nursing and allied health professionals. • Reviews complex clinical issues with the coding staff to assign a working DRG, identifies educational opportunities, and seeks guidance as needed. • Analyzes inpatient records for appropriateness and compliance with all federal, state, and other regulatory requirements. • Maintains current knowledge of all issues related to coding, diagnosis, treatment, and reimbursement. • Serves as an expert resource to all levels of clinical staff and participates in the development of curriculum for in-service trainings and education of professional staff to achieve improved results in clinical documentation and appropriate reimbursement. • Participates in tracking responses to clinical documentation integrity improvement efforts and trends in compliance. Suggests strategies to address trends. • Maintains a customer service focus. • Serves on CDI Task Force and supports project related activities • Assists in special projects as needed. Rush is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, and other legally protected characteristics. **Position** Clinical Doc Specialist RN 2 **Location** US:IL:Chicago **Req ID** 15850