Clinical Documentation Specialist

Job Summary

Join our team and be a part of our mission to deliver accessible, high-quality, affordable, and compassionate healthcare. Prairie Lakes Healthcare System is a non-profit healthcare system serving 10 counties in northeastern South Dakota and west-central Minnesota. Our team at Prairie Lakes makes a difference in the lives of patients and their loved ones.

About the role

Wage: $28.09 - $44.81 per hour
On-site presence in Watertown, SD is required during the first year. This full-time position has the option to be Remote, On-site (Watertown, SD), or Hybrid after the first year.

Responsibilities

• Communicates with providers, nursing staff, case managers, coders, and other members of the healthcare team to facilitate complete, accurate, and compliant clinical documentation in the inpatient medical record.
• Serves as a resource to providers by linking clinical documentation requirements, coding guidelines, and medical terminology to improve the accuracy and completeness of final code assignment.
• Works collaboratively with the coding department in concurrent review of the inpatient medical record to support appropriate diagnosis related group (DRG) assignment and documentation integrity.
• Reviews clinical documentation issues with coding staff to identify missed opportunities related to documentation specificity, coding guidelines, and reimbursement, and helps prevent future missed opportunities through education and process improvement.
• Demonstrates knowledge of clinical documentation standards, coding guidelines, DRGs, medical necessity requirements, and payer regulations, and provides clarification and education to providers and internal customers as needed.
• Maintains accurate and organized records of review activities, findings, queries, and outcomes in accordance with departmental, regulatory, and compliance requirements.
• Acts as a consultant to coding staff when additional information or documentation is needed to support correct code assignment.
• Facilitates collaboration among providers, coders, case managers, and ancillary/support departments to improve documentation practices, support quality outcomes, and reduce duplication and variation.

Qualifications

• Education and/or Experience:
  • Bachelor’s degree in nursing required.
  • Graduate from a nationally accredited nursing program preferred.
  • Three years of recent clinical nursing experience required.
  • Experience in case management, utilization management, and/or coding preferred.
• Certificates, Licenses, Registrations:
  • Currently holds an unencumbered RN license in the State of South Dakota, or is eligible for current licensure in the State of South Dakota, and/or possesses multistate licensure if practicing in a Nurse Licensure Compact state.
  • Maintains required department-specific competencies and certifications.
  • Certification as a Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement and Integrity (C-CDI) preferred.

Benefits

Prairie Lakes Healthcare System offers comprehensive benefits for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a 403(b)-retirement plan, and generous paid time off to maintain a healthy home-work balance. Additional benefits for those qualifying include: Flexible Spending Account, Employee Assistance Program for mental health, Education Loan Program, Community discounts including the Prairie Lakes Wellness Center, and a Drug Free Workplace Policy.