SINAI CHICAGO CLINICAL DOCUMENTATION SPECIALIST-HOSPITAL

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 – 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’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:

• Conducts concurrent clinical documentation reviews for assigned inpatient cases to identify opportunities for clarification and improved specificity.
• Initiates compliant physician queries to obtain clarification or additional documentation that impacts coding, DRG assignment, SOI, ROM, and quality outcomes.
• Collaborates with physicians, advanced practice providers, and coding teams to ensure documentation accurately reflects the patient's clinical picture and supports coded data.
• Participates in daily clinical rounds, case management discussions, and multidisciplinary meetings to proactively identify documentation gaps.
• Reviews documentation related to key quality metrics such as PSI, HAC, mortality, and LOS variances.
• Reconciles CDI findings with coding results to ensure DRG accuracy and alignment between CDI and HIM.

• Education and Work Experience:

• Bachelor’s degree in Nursing, Health Information Management, or related healthcare field required.
• Master’s degree preferred
• Minimum of 3 years of clinical experience in acute care nursing (ICU, Med/Surg, Telemetry, etc.) or equivalent.
• Minimum of 2 years of experience in CDI, inpatient coding, or case management.

• Knowledge and Skills:

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

• Certifications/Licenses:

• Active RN, LPN, RHIA, or RHIT credential required.
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) strongly preferred (or obtained within 12 months of hire)

Location: SHS · SHS SHS PATIENT ACCOUNTS
Schedule: Full Time, Days, 9am-5pm