Clinical Documentation Specialist

Welcome to Universal Health Services, where we are dedicated to providing high-quality and compassionate care to our patients. We are currently seeking a highly skilled Clinical Documentation Specialist to join our team. In this role, you will play a crucial part in ensuring accurate and complete medical records, allowing us to deliver the best possible care to our patients. We are looking for a detail-oriented and knowledgeable individual who shares our passion for improving healthcare outcomes. If you have strong communication and analytical skills, as well as a background in healthcare documentation, we would love to hear from you.

1. Review and analyze patient medical records to ensure accuracy and completeness.
2. Collaborate with healthcare providers to gather necessary information and clarify documentation.
3. Identify and report any discrepancies or missing information in medical records.
4. Utilize coding and classification systems to accurately assign diagnoses and procedures.
5. Educate and train healthcare providers on proper documentation practices.
6. Stay up-to-date on industry regulations and guidelines related to medical documentation.
7. Maintain confidentiality and security of patient records.
8. Participate in quality assurance and improvement initiatives related to documentation.
9. Communicate effectively with interdisciplinary team members to ensure coordination of care.
10. Develop and maintain strong working relationships with healthcare providers and other staff.
11. Demonstrate a commitment to excellent patient care and outcomes.
12. Adhere to all organizational policies and procedures related to documentation and privacy.
13. Provide support and guidance to other team members as needed.
14. Identify opportunities for process improvement and efficiency.
15. Maintain organized and accurate documentation of all tasks and actions taken.
16. Attend training and professional development opportunities to continuously enhance skills and knowledge.
17. Adhere to strict deadlines and prioritize workload effectively.
18. Serve as a resource for colleagues regarding documentation best practices.
19. Ensure compliance with all regulatory requirements and standards.
20. Perform other duties as assigned by supervisors.

According to JobzMall, the average salary range for a Clinical Documentation Specialist in Chicago, IL, USA is between $58,000 - $85,000 per year. This may vary depending on the specific employer, years of experience, and qualifications of the individual.

Universal Health Services, Inc. (UHS) is one of the largest and most respected providers of hospital and healthcare services in the nation with more than 90,000 employees dedicated to improving people’s lives and transforming the delivery of healthcare. Through its subsidiaries, the company operates 26 Acute Care hospitals, 328 Behavioral Health inpatient facilities, and 42 outpatient facilities and ambulatory care centers in 37 states in the U.S., Washington, D.C., Puerto Rico and the United Kingdom. UHS also offers health insurance plans through Prominence Health Plan, and manages a network of physicians through Independence Physician Management.