RN Clinical Documentation Specialist: Elevate Medical Records

Sanford; Fargo (ND); On-site; USD 38,000 - 61,000; Full time

Job summary

Sanford Health in the United States is seeking a Clinical Documentation Specialist (CDS) to collaborate with providers, case managers, coders, and other healthcare professionals to ensure accurate inpatient documentation reflecting treatment, decisions, and diagnoses.

The CDS utilizes the hospital's CDI system to identify opportunities for documentation improvement, provides education on compliance and coding, and consults with coders to assign appropriate DRGs.

Qualifications

• Bachelor's degree in nursing required.
• Three years of recent clinical nursing experience required.
• RN license in good standing; CCDS/C-CDI preferred.

Responsibilities

• Communicate with providers, case managers, coders and care team to facilitate accurate documentation for inpatient care.
• Use the hospital's CDI system to identify opportunities for documentation improvement and education on compliance and coding.
• Consult with coders when additional information is needed to assign the correct DRG.
• Evaluate documentation day-to-day and analyze information relevant to documentation findings.
• Demonstrate strong written and verbal communication, critical thinking and problem solving.

Skills

RN license

Case management

Utilization management

Coding

Communication skills

Education

Bachelor's degree in nursing

Job description

Sanford Health in the United States is seeking a Clinical Documentation Specialist (CDS) to collaborate with providers, case managers, coders, and other healthcare professionals to ensure accurate inpatient documentation reflecting treatment, decisions, and diagnoses.

The CDS utilizes the hospital's CDI system to identify opportunities for documentation improvement, provides education on compliance and coding, and consults with coders to assign appropriate DRGs.