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Job Details

Clinical Documentation Specialist CDI

Company name
Vista Health System

Waukegan, IL

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Clinical Documentation Specialist (CDI)

Job Description

Apply Now at Vista Health System

and begin working and servicing patients in our community! Invest your time in providing quality care for the communities we serve!

Vista Health System

is a community healthcare provider; a network that includes Vista Medical East campus and the Vista Lindenhurst campus that includes Vista Ambulatory Care Center, Lindenhurst Surgery Center, LLC, a freestanding Emergency Center and the Medical Office Building. The Vista Health system also has several locations for imaging, patient therapy and physician offices throughout Lake County, Illinois.

Vista Health System

is looking for a Clinical Documentation Improvement Specialist (CDI)

who is responsible for improving the overall quality and completeness of clinical documentation.

Clinical Documentation Improvement Specialist (CDI)

Responsibilities to include:

Collaborates extensively with physicians, nursing staff, other patient caregivers, and Health Information Management coding staff to support that appropriate reimbursement and clinical severity is captured for the level of service rendered to all patients with a DRG based payer.

Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.


: Performs concurrent documentation review of selected inpatient records to clarify conditions/diagnoses and procedures where inadequate or conflicting documentation exists. While patient is in-house, will update DRG, every 48 hours or as indicated, to reflect any changes in status, procedures/treatments, etc. Works with Physician Advisor as indicated to obtain healthcare provide compliance.


: Improves coding specificity by educating physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided throughout a patient’s stay. This includes medical necessity and capturing complications/co-morbidities during the patient’s stay. This is achieved via queries, face-to-face communications, and/or other educational programs and tools useful and necessary to achieve this goal.


: Follows guidelines for coding and documentation to ensure physician and hospital compliance. Remains current with coding information to ensure accuracy of codes assigned based on documentation. Information will include the AHA Coding Clinic

publication, pharmacology, laboratory, disease processes, and new/emerging technologies.

Communication and Relationship Building

: Builds trusting, collaborative relationships with staff, peers, other disciplines, ancillary services, and physicians. Builds credibility with physicians as a champion for patient care, quality and HIM/Nursing professionalism. Collaborates with all members of the interdisciplinary healthcare team to achieve goals.

Data Base Collection

: Keeps daily production logs containing number of cases reviewed, number of queries placed/responded, etc. for weekly evaluation of output. Updates the PHIIP key metrics grid on a daily basis and completes the final report at month end.

Quality & Performance Improvement

: Identify opportunities for intradepartmental and interdepartmental operational improvements, monitors and evaluates effectiveness of concurrent coding outcomes at designated intervals and reports concurrent coding outcomes to hospital departments and medical staff committees as requested. Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s medical record.

We offer a competitive benefit package of Medical, Dental and Vision plans. 401K, Education Assistance, Paid Time Off / Sick Leave and much more!


Education requirements - RN, BSN, CCDS, CDIP, RHIA, RHIT, or CCS or combination there of.

A minimum of two years’ experience in nursing, or other clinical area, coding, process improvement, or utilization review/case management in an acute care facility.

Coding Skills with experience in ICD-10-CM and working knowledge of the AHA Coding Clinic

Effective interpersonal skills in order to interact effectively with all levels of hospital personnel.

Organization and prioritization skills.

Effective written and verbal communication skills.

Analytical skills and proficient computer skills.


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Company info

Vista Health System
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