SINAI CHICAGO CLINICAL DOCUMENTATION SPECIALIST-HOSPITAL
Company: Sinai Health System
Location: Chicago
Posted on: February 1, 2026
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Job Description:
At Sinai Health System d/b/a Sinai Chicago, we take health care
personally. Excellence in health care is about more than just
medicine, technology, tests, and treatments, it is about really
caring for people with dignity and respect. That is what we do. We
are dedicated to providing the best care to meet the needs of
people, for our community, for our patients and for you. Position
Purpose: The Clinical Documentation Integrity Specialist - Hospital
Based (CDIS-HB) is responsible for performing concurrent and
retrospective reviews of inpatient medical records to ensure the
accuracy, completeness, and integrity of clinical documentation.
The CDIS collaborates closely with providers, coding professionals,
and utilization review teams to ensure that clinical documentation
accurately reflects the patient's severity of illness (SOI), risk
of mortality (ROM), and resource utilization. This role directly
supports compliance, accurate DRG assignment, and appropriate
reimbursement while advancing quality and performance improvement
initiatives throughout the organization. Key Job Activities:
Conducts concurrent clinical documentation reviews for assigned
inpatient cases to identify opportunities for clarification and
improved specificity. Initiates compliant physician queries to
obtain clarification or additional documentation that impacts
coding, DRG assignment, SOI, ROM, and quality outcomes.
Collaborates with physicians, advanced practice providers, and
coding teams to ensure documentation accurately reflects the
patient's clinical picture and supports coded data. Participates in
daily clinical rounds, case management discussions, and
multidisciplinary meetings to proactively identify documentation
gaps. Reviews documentation related to key quality metrics such as
PSI, HAC, mortality, and LOS variances. Reconciles CDI findings
with coding results to ensure DRG accuracy and alignment between
CDI and HIM. Education and Work Experience: Bachelor's degree in
Nursing, Health Information Management, or related healthcare field
required. Master's degree preferred Minimum of 3 years of clinical
experience in acute care nursing (ICU, Med/Surg, Telemetry, etc.)
or equivalent. Minimum of 2 years of experience in CDI, inpatient
coding, or case management. Knowledge and Skills: Working knowledge
of ICD-10-CM/PCS, MS-DRG and APR-DRG methodology, and clinical
validation guidelines. Experience using 3M, Optum, or other CDI
platforms preferred. Excellent clinical judgment and critical
thinking skills. Ability to interpret complex clinical data and
translate it into accurate documentation. Certifications/Licenses:
Active RN, LPN, RHIA, or RHIT credential required. Certified
Clinical Documentation Specialist (CCDS) or Certified Documentation
Improvement Practitioner (CDIP) strongly preferred (or obtained
within 12 months of hire) Additional Information NA
Keywords: Sinai Health System, Oak Park , SINAI CHICAGO CLINICAL DOCUMENTATION SPECIALIST-HOSPITAL, Healthcare , Chicago, Illinois
