Qureos Mentor

Sinai Chicago

<div>About Us:
At Sinai Health System d/b/a Sinai Chicago, we take health care personally. Excellence in health care is about more than just medicine, technology, tests, and treatments, it is about really caring for people with dignity and respect. That is what we do. We are dedicated to providing the best care to meet the needs of people, for our community, for our patients and for you.
Position Purpose:
The Physician-based Clinical Documentation Integrity Specialist (CDIS) is responsible for improving the overall quality, accuracy, and completeness of clinical documentation within physician practice and ambulatory settings. The CDIS works collaboratively with physicians, advanced practice providers, coders, and revenue cycle staff to ensure documentation reflects the patient&rsquo;s clinical status, risk adjustment, and quality metrics. This role plays a key part in optimizing physician performance under value-based care models, HCC risk adjustment, and outpatient revenue integrity initiatives. 

Key Job Activities:
<ul><li>Conducts prospective and retrospective reviews of physician and advanced practice provider documentation to ensure accuracy, completeness, and compliance with CMS and payer-specific guidelines.</li>
<li>Identifies opportunities for documentation improvement that supports accurate risk adjustment coding (HCC/RAF) and capture of chronic conditions and comorbidities.</li>
<li>Develops and issues compliant provider queries for clarification or additional documentation to support coding and quality outcomes.</li>
<li>Partners with coders and revenue integrity teams to ensure alignment between documentation and assigned CPT, ICD-10-CM, and HCC codes.</li>
<li>Provides one-on-one and group education to physicians and clinical staff regarding documentation best practices, HCC/RAF impact, and compliant coding.</li></ul> 

<ul><li>Education and Work Experience:
</li><li>Bachelor&rsquo;s degree in Nursing, Health Information Management, or related healthcare field required.</li>
<li>Master&rsquo;s degree preferred</li>
<li>Minimum 3 years of clinical experience in ambulatory or physician practice settings</li>
<li>Minimum 2 years of experience in CDI, risk adjustment, or coding</li></ul> 

<ul><li>Certifications/Licenses:
</li><li>Active RN, RHIA, or RHIT license/certification required.</li>
<li>Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP), or Certified Risk Adjustment Coder (CRC) preferred (or obtained within 12 months of hire).</li>
</ul> 
Location: SHS &middot; SHS SHS PATIENT ACCOUNTS 
Schedule: Full Time, Days, 9am-5pm</div>

SINAI CHICAGO CLINICAL DOCUMENTATION SPECIALIST-PHYSICIAN

<div>At Sinai Health System d/b/a Sinai Chicago, we take health care personally. Excellence in health care is about more than just medicine, technology, tests, and treatments, it is about really caring for people with dignity and respect. That is what we do. We are dedicated to providing the best care to meet the needs of people, for our community, for our patients and for you.
Position Purpose:
The Clinical Documentation Integrity Specialist &ndash; Hospital Based (CDIS-HB) is responsible for performing concurrent and retrospective reviews of inpatient medical records to ensure the accuracy, completeness, and integrity of clinical documentation. The CDIS collaborates closely with providers, coding professionals, and utilization review teams to ensure that clinical documentation accurately reflects the patient&rsquo;s severity of illness (SOI), risk of mortality (ROM), and resource utilization.
This role directly supports compliance, accurate DRG assignment, and appropriate reimbursement while advancing quality and performance improvement initiatives throughout the organization. 

Key Job Activities:
<ul><li>Conducts concurrent clinical documentation reviews for assigned inpatient cases to identify opportunities for clarification and improved specificity.</li>
<li>Initiates compliant physician queries to obtain clarification or additional documentation that impacts coding, DRG assignment, SOI, ROM, and quality outcomes.</li>
<li>Collaborates with physicians, advanced practice providers, and coding teams to ensure documentation accurately reflects the patient's clinical picture and supports coded data.</li>
<li>Participates in daily clinical rounds, case management discussions, and multidisciplinary meetings to proactively identify documentation gaps.</li>
<li>Reviews documentation related to key quality metrics such as PSI, HAC, mortality, and LOS variances.</li>
<li>Reconciles CDI findings with coding results to ensure DRG accuracy and alignment between CDI and HIM.</li>
<li>Education and Work Experience:
</li><li>Bachelor&rsquo;s degree in Nursing, Health Information Management, or related healthcare field required.</li>
<li>Master&rsquo;s degree preferred</li>
<li>Minimum of 3 years of clinical experience in acute care nursing (ICU, Med/Surg, Telemetry, etc.) or equivalent.</li>
<li>Minimum of 2 years of experience in CDI, inpatient coding, or case management.</li></ul> 

<ul><li>Knowledge and Skills:
</li><li>Working knowledge of ICD-10-CM/PCS, MS-DRG and APR-DRG methodology, and clinical validation guidelines.</li>
<li>Experience using 3M, Optum, or other CDI platforms preferred.</li>
<li>Excellent clinical judgment and critical thinking skills.</li>
<li>Ability to interpret complex clinical data and translate it into accurate documentation.</li></ul> 

<ul><li>Certifications/Licenses:
</li><li>Active RN, LPN, RHIA, or RHIT credential required.</li>
<li>Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) strongly preferred (or obtained within 12 months of hire)</li>
</ul> 
Location: SHS &middot; SHS SHS PATIENT ACCOUNTS 
Schedule: Full Time, Days, 9am-5pm</div>

SINAI CHICAGO CLINICAL DOCUMENTATION SPECIALIST-HOSPITAL

Join Sinai Chicago and explore 2   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.

Sinai Chicago

ABOUT_COMPANY

SINAI CHICAGO CLINICAL DOCUMENTATION SPECIALIST-PHYSICIAN

SINAI CHICAGO CLINICAL DOCUMENTATION SPECIALIST-HOSPITAL