Clinical Documentation Specialist

Facilitate necessary documentation in the medical record through extensive interaction with physicians, HIM, and coding staff to ensure appropriate reimbursement and the highest level of severity of illness/risk of mortality. Educate physicians regarding clinical documentation needs, guideline changes, and coding opportunities. Apply medical terminology knowledge to evaluate documents for reimbursement and perform acute care inpatient medical record monitoring of diagnoses, treatments, and follow-up entries to validate accuracy. Obtain missing information via query when necessary. This fully remote engagement supports Cook County Health under limited direction, adhering to established clinical documentation guidelines and policies.