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Clinical Documentation Nurse

Memorial Health

Memorial Health

Decatur, IL, USA
Posted on Thursday, May 16, 2024

Clinical Documentation Nurse

Job Locations US-IL-Decatur
Registered Nurse (RN) (Experienced)
Position Type


Utilizes clinical and nursing knowledge of documentation requirements to improve overall quality and completeness of clinical documentation of patient records. Works collaboratively with physicians to ensure clinical information in medical record is present and accurate to guarantee the appropriate clinical severity is captured for the level of services rendered.


  • Current Active license as a Professional Registered Nurse in the State of Illinois.
  • Three (3) years of recent clinical nursing experience in an acute-care hospital.
  • Certification in Clinical Documentation Improvement through AHIMA and/or ACDIS preferred.


  • Facilitates appropriate clinical documentation to support the appropriate diagnosis and procedure coding and to ensure the level of service rendered to all patients is recorded.
  • Follows documentation improvement processes for conducing medical record reviews and meets goals related to appropriate documentation.
  • Assigns a working DRG using coding rules and guidelines.
  • Works with physicians on assigned patient care units to clarify documentation in the medical record.
  • Queries physicians on a concurrent and retroactive basis to ensure documentation appears on the medical prior to billing.
  • Reviews clinical issues with the Health Information Management (HIM) coding staff to assign a working DRG.
  • Identifies missed opportunities related to clinical documentation and coding guidelines and works to ensure accuracy for future coding.
    • Works with Coders, Coding Team Leads and/or Coding Supervisor to resolve differences between CDI and Coding Staff.
  • Coordinates documentation improvement processes with physicians and HIM coding staff to identify those diagnoses that impact severity of illness indicators for each patient.
  • Collaborates with the multidisciplinary team to reflect quality patient outcomes.
  • Identifies clinical indicators that suggest a need for clarification.
  • Adheres to hospital standards to promote a cooperative work environment by utilizing communication skills, interpersonal relationships, and team building.
  • Contributes to the overall quality of services.
  • Assumes responsibility for keeping informed about changes in policies and procedures.
  • Communicates information effectively.
  • Demonstrates responsibility for personal development by participating in continuing education offerings.
  • Maintains competence related to DRG assignment, documentation requirements and coding guidelines.
  • Perform other job-related duties as required.


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