Clinical Documentation Specialist
Job 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. 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).
Responsibilities
- Evaluate documentation by the medical staff and healthcare team.
- Analyze information pertinent to documentation findings and outcomes.
- Facilitate and negotiate with others.
- Control variances and duplication.
- Document clearly.
- Solve problems.
- Facilitate groups and implement projects when necessary.
Qualifications
- Bachelor’s degree in nursing required.
- 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 possesses multistate licensure if in a Nurse Licensure Compact (NLC) state.
- Obtains and subsequently maintains required department specific competencies and certifications.
- Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement and Integrity (C-CDI) certification preferred.
Benefits
Sanford offers an attractive benefits package 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 401(k) retirement plan, work/life balance benefits, and a generous time off package to maintain a healthy home-work balance. For more information about Total Rewards, visit here.
About the Role
Facility: Central Patient Building
Location: Sioux Falls, SD
Address: 1305 W 18th St, Sioux Falls, SD 57117, USA
Shift: 8 Hours - Day Shifts
Job Schedule: Full time
Weekly Hours: 40.00
Salary Range: $27.50 - $44.00
Department Details
This position is five days per week, no nights, weekends, or holidays. Eight-hour workdays with 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.
Skills
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.
Benefits
Sanford offers an attractive benefits package 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 401(k) retirement plan, work/life balance benefits, and a generous time off package to maintain a healthy home-work balance. For more information about Total Rewards, visit here.