Clinical Documentation Specialist - Full Time

Facility: Central Patient Building
Location: Sioux Falls, SD
Address: 1305 W 18th St, Sioux Falls, SD 57117, USA

Job Summary

The Clinical Documentation Specialist (CDS) communicates with providers, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation that reflects clinical treatment, decisions, and diagnoses for inpatients/residents. The CDS uses the hospital’s clinical documentation system to identify opportunities for improved physician and hospital outcomes, provides education on compliance, coding, and documentation, and consults with coders to ensure accurate diagnosis‑related group (DRG) assignment. The role evaluates documentation daily, analyzes findings, contributes to a positive work environment, and performs additional duties as assigned.

Responsibilities

• Communicate with providers, case managers, coders, and other team members to ensure complete medical record documentation.
• Utilize the hospital’s clinical documentation system to identify documentation improvement opportunities.
• Provide or coordinate education on compliance, coding, and clinical documentation for internal customers.
• Act as a consultant to coders when additional information is needed for correct DRG assignment.
• Evaluate documentation day‑to‑day, gather and analyze pertinent information, and report findings.
• Maintain advanced communication and interpersonal skills with all internal and external customers.
• Demonstrate excellent written and verbal communication, critical thinking, creative problem solving, and conflict management.
• Organize and plan work efficiently; exhibit strong computer skills (spreadsheets, presentations, word processing, Internet research).
• Apply knowledge of quality‑improvement theory and practice.
• Maintain working knowledge of DRGs and the medical necessity process.
• Stay knowledgeable of federal, state, and payer regulations, requirements, and criteria.
• Adhere to ethical and professional standards (ACDIS code of ethics, official coding guidelines).
• Reference professional documentation resources such as white papers from ACDIS, AHIMA, and other organizations.
• Perform record reviews for patients of all age groups as needed.
• Coordinate, facilitate, and negotiate with various stakeholders.
• Control variances and duplication in documentation.
• Collaborate closely with ancillary and support services.
• Document clearly and accurately.
• Solve problems and facilitate groups; implement projects when required.
• Operate within the scope and standards of nursing practice as defined by the Nurse Practice Act and state administrative rules.
• Uphold the Scope and Standards of Practice and the ANA Code of Ethics for Nurses.

Qualifications

• Bachelor’s degree in nursing required (or seven years equivalent work experience if no degree).
• Graduation from a nationally accredited nursing program preferred (CCNE, ACEN, NLN CNEA).
• Minimum three years of recent clinical nursing experience.
• Experience in case management, utilization management, and/or coding preferred.
• Current, unencumbered RN license with the State Board of Nursing (or multistate licensure in an NLC state).
• Maintain required department‑specific competencies and certifications.
• Certification as a Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement and Integrity (C‑CDI) preferred.
• Quality‑improvement/assurance personnel with nursing backgrounds may retain their license without additional clinical hours.

Schedule

• Shift: 8‑hour day shifts.
• Job schedule: Full‑time, 36 hours per week.
• Department 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.
• On‑site training with the possibility of remote work after one year or sooner when proficient.

Pay

Salary range: $29.00 – $44.00 per hour.

Benefits

• Health, dental, and vision insurance.
• Life insurance.
• 401(k) retirement plan.
• Work‑life balance benefits.
• Generous paid time off to support a healthy home‑work balance.
• Additional Total Rewards information available at Sanford Careers – Benefits.