Clinical Documentation Specialist (RN)

Hybrid role: Three days a week on site, two days remote.

Pay Range:

• Aurora St. Luke’s Medical Center, one of Wisconsin’s premier tertiary care and academic medical centers
• Hybrid work environment with an expectation to be on-site three days per week
• Collaborative team environment working closely with physicians, nursing leaders, coders, and clinical staff
• Opportunity to leverage your clinical expertise in a non-bedside role that directly impacts patient care quality and organizational outcomes

• Registered Nurses (RN) with a minimum of 2 years of recent clinical nursing experience
• preference for candidates with ICU or other high-acuity inpatient experience
• Current Registered Nurse (RN) license issued by the state of Wisconsin in which the team member practices
• Associate Degree in Nursing (ADN) required
• Nurses who possess:
  • Strong clinical judgment and critical thinking abilities
  • High-acuity patient care experience and the ability to recognize complex clinical presentations
  • Knowledge and recognition of medications and treatment regimens
  • Strong communication and collaboration skills
  • Comfort working in electronic medical records and Microsoft Word
  • Ability to work independently while partnering effectively with providers and interdisciplinary teams
  • Availability to work on-site two days per week

• Review inpatient medical records concurrently to ensure accurate, complete, and compliant clinical documentation.
• Conduct comprehensive chart reviews to identify co-morbidities, complications, quality indicators, and opportunities for documentation improvement.
• Collaborate with physicians, nurses, and coding professionals to identify principal and secondary diagnoses, procedures, and appropriate DRG assignments.
• Utilize the physician query process to clarify clinical documentation and accurately reflect patient severity of illness, risk of mortality, and complexity of care.
• Support quality metrics, reimbursement accuracy, and regulatory compliance through effective documentation practices.
• Identify, evaluate, and help resolve barriers to meeting clinical documentation standards.
• Monitor and track Clinical Documentation Integrity (CDI) program outcomes using established tools and reporting processes.
• Identify quality variances and documentation opportunities that can be addressed concurrently during the patient's admission.
• Serve as an educator and resource to physicians and clinical staff regarding documentation requirements, best practices, and query responses.
• Build and maintain positive working relationships across interdisciplinary teams while promoting documentation excellence and problem-solving.

Our Commitment to You:

Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including:

Compensation

• Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training

• Premium pay such as shift, on call, and more based on a teammate's job

• Incentive pay for select positions

• Opportunity for annual increases based on performance

Benefits and more

• 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

Note: Eligibility for programs listed above may depend on your FTE or status (e.g., full-time, part-time, per diem, temporary, etc.); please ask a Recruiter for more information during an interview.