Clinical Documentation Integrity RN/LPN

Company: The Judge Group
Location: Chicago
Posted on: May 23, 2025

Job Description:

Location: Chicago, IL, USASalary: $45.00 USD Hourly - $50.00 USD HourlyDescriptionJudge Healthcare is looking for a Clinical Documentation Integrity RN or LPN to work remote for one of our top clients!Job SummaryThe Clinical Documentation Improvement (CDI) RN or LPN leverages clinical and coding expertise to conduct concurrent and retrospective reviews of inpatient and outpatient medical records. The goal is to enhance the quality of clinical documentation, focusing on areas identified by CDI leadership, such as mortality reviews and PSI reviews.Essential Functions

• Review clinical documentation to accurately represent the severity of illness, risk of mortality, and complexity of care.
• Communicate review results to leadership, CDI Specialists, and other staff, recommending corrective actions.
• Conduct focused reviews in areas identified by CDI leadership.
• Develop and present ongoing education for CDI specialists and related departments on documentation trends and CDI practices.
• Educate physicians and healthcare providers on documentation trends and CDI practices.
• Evaluate CDI accuracy and standardize review findings.
• Identify trends, variances, and deficiencies using aggregated data.
• Monitor the effectiveness of concurrent medical record reviews and queries.
• Collaborate with CDI Director, HIMS coding, Quality, and Compliance to ensure accurate diagnostic and procedural data.
• Serve as a subject matter expert on CDI practices, coding rules, and regulations.
• Utilize hospital coding policies, federal and state guidelines, and Coding Clinic Guidelines to assign working DRG.
• Initiate physician interaction for additional documentation when necessary.
• Partner with HIMS coding staff to ensure accurate diagnostic and procedural data.Minimum Requirements
  • Associates or Bachelor's degree in Nursing
  • Five years of progressively responsible clinical work experience.
  • Three years of experience as a Clinical Documentation Improvement Specialist.
  • Experience with MS-DRG and APR-DRG focused reviews.
  • At least one year of supervisory experience (preferred).
  • Experience with quality outcomes focused CDI reviews (preferred).Licenses/Certifications
    • RN or LPN required.
    • CCDS certification through ACDISThis role is critical in ensuring the accuracy and quality of clinical documentation, which directly impacts patient care and compliance with regulatory standards.By providing your phone number, you consent to: (1) receive automated text messages and calls from the Judge Group, Inc. and its affiliates (collectively "Judge") to such phone number regarding job opportunities, your job application, and for other related purposes. Message & data rates apply and message frequency may vary. Consistent with Judge's Privacy Policy, information obtained from your consent will not be shared with third parties for marketing/promotional purposes. Reply STOP to opt out of receiving telephone calls and text messages from Judge and HELP for help.Contact: bkirking@judge.comThis job and many more are available through The Judge Group. Find us on the web at www.judge.com

Keywords: The Judge Group, Buffalo Grove , Clinical Documentation Integrity RN/LPN, Healthcare , Chicago, Illinois