This position requires Illinois residency within 180 days of the hire date.
Salary
Final salary offered will be determined by a thorough assessment of available market data, internal salary equity, candidate experience and qualifications, and budget constraints.
About the University of Illinois Hospital & Health Sciences System (UI Health)
The University of Illinois Hospital & Health Sciences System (UI Health) provides comprehensive care, education, and research to the people of Illinois and beyond. It is part of the University of Illinois Chicago (UIC) and includes a Joint Commission‑accredited tertiary care hospital, outpatient clinics, a Mile Square Health Center network, and the seven UIC health science colleges. UI Health is dedicated to the pursuit of health equity.
This position is eligible for benefits including Health, Dental, Vision, Life Insurance, a Retirement Plan, Paid time Off, and Tuition waivers for employees and dependents.
Position Summary
The Lead Clinical Documentation Specialist assists with the day‑to‑day oversight and reviews the progress of the Clinical Documentation Improvement program through interpretation of CDI and quality rating reports under the leadership of the Clinical Documentation Improvement Director. The role leads, provides, and maintains CDI practices to ensure consistency and meet coding rules, query compliance, and organization compliance guidelines. The specialist works with the CDI Director, CDISs, Quality, and HIM departments in managing patient encounters that may include DRG optimization, clinical denials, quality measures, and mortality reviews.
Duties & Responsibilities
Assist the Clinical Documentation Improvement Director with daily oversight of the CDI team.
Track CDI productivity metrics, perform quality reviews, capture areas for improvement, identify educational needs, and prioritize workload.
Conduct case reviews, initiate queries, and perform reconciliation per CDI workflows.
Strategize process refinements to capture opportunity within the CDI team based on reviews.
Collaborate with HIM, Coding, Quality, Case Management, and Compliance to ensure accurate documentation for reimbursement and quality reporting.
Assist in clinical denials management and identify opportunities to reduce future denials.
Serve as a subject matter expert in clinical data reporting and lead overall quality and completeness of CDI by applying evidence‑based knowledge.
Monitor internal CDI key indicators related to revenue cycle, provider performance, and quality outcomes.
Identify opportunities for provider education to improve medical record documentation accuracy.
Onboard and provide ongoing competency development for the CDI team; participate in CDI‑related projects.
Collaborate with providers to clarify documentation to accurately reflect patient conditions.
Perform other related duties and participate in special projects as assigned.
Minimum Qualifications
Licensure as a Registered Professional Nurse in Illinois.
Bachelor’s degree in nursing (BSN) or health‑related field.
Minimum of 4 years of acute care clinical nursing experience.
Minimum of 3 years of Clinical Documentation Improvement experience in the acute care setting.
Ability to interact with providers, leadership, and coworkers with tact, discretion, and diplomacy.
Strong oral and written communication skills and organizational flexibility.
Intermediate to advanced proficiency with Microsoft Office Suite.
Other Knowledge Base Skills
Knowledge of ICD‑10‑CM/PCS coding guidelines, CMS guidelines, and quality measures.
Proficiency in CDI/encoder software (3M/Solventum/Optum, Epic EMR).
Ability to analyze data and prepare PowerPoint presentations.
Ability to analyze data to drive performance and priorities for improvement.
Preferred Qualifications
Master’s degree in nursing (MSN) or another healthcare‑related field.
At least 2 years of supervisory/administrative experience in a health care setting.
At least 2 years of CDI educator or CDI auditing experience.
To Apply
For fullest consideration, click the “Apply Now” button and fully complete all sections of the online application, including work history, education, licensure, certification, and language sections. Upload a resume, cover letter, certifications, licensures, transcripts, and diplomas within the application. Once submitted, changes cannot be made; you must withdraw and reapply if necessary. Ensure all documents are uploaded before the posting close date.
Equal Opportunity
The University of Illinois System is an equal opportunity employer, including but not limited to disability and/or veteran status, and complies with all applicable state and federal employment mandates. The university provides accommodations to applicants and employees. Request an accommodation if needed. The university also complies with required background checks, sexual harassment/misconduct disclosures, and eligibility reviews through E‑Verify.
To apply, visit https://uic.csod.com/ux/ats/careersite/1/home/requisition/17222?c=uic