RN Clinical Documentation Specialist

sanford; Sioux Falls (SD); Hybrid; USD 40,000 - 61,000; Full time

Job summary

Sanford Health is seeking a Clinical Documentation Specialist to improve medical record documentation for DRG accuracy. The CDS will collaborate with providers, case managers, and coders to reflect treatment decisions accurately in inpatient records.

Requirements include a Bachelor’s in nursing, an active RN license, and strong communication and problem-solving skills. A CCDS/CCDI is preferred, with potential for remote work after one year.

Qualifications

• Bachelor's degree in nursing is required.
• RN license in the state of practice is required.
• Three years of clinical nursing experience required.
• CCDS or CCDI certification preferred; coding experience is a plus.

Responsibilities

• Communicate with providers and care team to ensure accurate documentation.
• Identify opportunities for DRG-based coding and provide education.
• Review records for compliance with regulations and accuracy.
• Coordinate with coders and internal customers to improve documentation.
• Maintain professional documentation standards across the team.

Skills

Clinical documentation

Communication

Critical thinking

Team collaboration

Education

Bachelor's degree in nursing

RN license

CCDS or CCDI certification preferred

Tools

EHR systems

Job description

Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America's heartland.

Basic Information

Work Shift: 8 Hours - Day Shifts (United States of America)

Scheduled Weekly Hours: 36

Compensation: Salary Range: $29.00 - $44.00

Union Position: No

Department Details

Schedule: 72 hours per pay period

• Week 1: Five 8-hour day shifts
• Week 2: Four 8-hour day shifts
• No Holidays
• Offers flexibility in start and end times to meet business needs
• Training on-site with consideration of remote work after one year or possibly sooner when proficient in job role
• Position will consist of medical record documentation review of complex patient populations
• Opportunity to work with a dynamic and engaging team

Summary

The Clinical Documentation Specialist (CDS) communicates with providers, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients/residents.

Job Description

The CDS utilizes the hospital's designated clinical documentation system to identify opportunities for physician and hospital outcomes, provides or coordinates education to all internal customers related to compliance, coding, and clinical documentation issues and acts as a consultant to coders when additional information or documentation is needed to assign the correct diagnosis related group (DRG). Responsible for the day-to-day evaluation of documentation by the medical staff and healthcare team, and gathers and analyzes information pertinent to documentation findings and outcomes. Contributes to a positive working environment and performs other duties as assigned or directed to enhance the overall efforts of the organization.

Must possess advanced communication and interpersonal skills with all levels of internal and external customers. Demonstrate excellent written/verbal communication, critical thinking, creative problem solving, and conflict management skills. Proficient in organization and planning. Possess strong computer skills including the use of spreadsheets, presentation programs, word processing, and Internet searching. Also demonstrates working knowledge of quality improvement theory and practice. Maintains working knowledge of DRGs and understanding of medical necessity process. Knowledgeable of federal, state, and other payers' regulations, requirements, and criteria. Adheres to ethical and professional business practices, such as the Association of Clinical Documentation Improvement Specialists (ACDIS) code of ethics and official coding guidelines. Utilizes the appropriate professional documentation to support daily processes, including white papers published by ACDIS, American Health Information Management Association (AHIMA), and other professional organizations.

May perform record reviews on clients in all age groups. Coordinates, facilitates, and negotiates with others. Controls variances and duplication. Must work closely with ancillary and support services. Ability to document clearly. Ability to solve problems. Ability to facilitate groups and implement projects when necessary.

Functions within the scope and standards of nursing practice as outlined in the Nurse Practice Act and Administrative Rules in state of practice and licensure. The Professional Nursing Practice recognizes the Scope and Standards of Practice and the Code of Ethics for Nurses with Interpretive Statements as published by the American Nurses Association as the foundation of nursing care delivery and professional conduct.

Qualifications

Bachelor's degree in nursing required. Graduate from a nationally accredited nursing program preferred, including, but not limited to, Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), and National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA). If no degree, will consider seven years equivalent work experience.

Additionally, three years of recent clinical nursing experience required. Experience in case management, utilization management, and/or coding preferred.

Currently holds an unencumbered RN license with the State Board of Nursing where the practice of nursing is occurring and/or possess multistate licensure if in a Nurse Licensure Compact (NLC) state. Obtains and subsequently maintains required department specific competencies and certifications. Certification in Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement and Integrity (C-CDI) preferred. Quality improvement/assurance personnel with nursing backgrounds can maintain their license without seeking additional hours based on role's responsibilities.

Sanford is an EEO/AA Employer M/F/Disability/Vet.

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