SINAI CHICAGO CLINICAL DOCUMENTATION SPECIALIST-PHYSICIAN at Sinai Chicago – Chicago, Illinois

About Us:

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 Physician-based Clinical Documentation Integrity Specialist (CDIS) is responsible for improving the overall quality, accuracy, and completeness of clinical documentation within physician practice and ambulatory settings. The CDIS works collaboratively with physicians, advanced practice providers, coders, and revenue cycle staff to ensure documentation reflects the patient’s clinical status, risk adjustment, and quality metrics. This role plays a key part in optimizing physician performance under value-based care models, HCC risk adjustment, and outpatient revenue integrity initiatives.

Key Job Activities:

• Conducts prospective and retrospective reviews of physician and advanced practice provider documentation to ensure accuracy, completeness, and compliance with CMS and payer-specific guidelines.
• Identifies opportunities for documentation improvement that supports accurate risk adjustment coding (HCC/RAF) and capture of chronic conditions and comorbidities.
• Develops and issues compliant provider queries for clarification or additional documentation to support coding and quality outcomes.
• Partners with coders and revenue integrity teams to ensure alignment between documentation and assigned CPT, ICD-10-CM, and HCC codes.
• Provides one-on-one and group education to physicians and clinical staff regarding documentation best practices, HCC/RAF impact, and compliant coding.

• Education and Work Experience:

• Bachelor’s degree in Nursing, Health Information Management, or related healthcare field required.
• Master’s degree preferred
• Minimum 3 years of clinical experience in ambulatory or physician practice settings
• Minimum 2 years of experience in CDI, risk adjustment, or coding

• Certifications/Licenses:

• Active RN, RHIA, or RHIT license/certification required.
• Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP), or Certified Risk Adjustment Coder (CRC) preferred (or obtained within 12 months of hire).