RN Clinical Documentation Specialist
Facility: Carufel Building, Fargo, ND (505 7th Ave N, Fargo, ND 58102, USA). Full-time, 40 hours per week, day shifts.
About the Role
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 utilizes the hospital's designated clinical documentation system to identify opportunities for physician and hospital outcomes, provides or coordinates education on compliance, coding, and clinical documentation issues, and acts as a consultant to coders when additional information 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, gathering and analyzing 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.
Responsibilities
- Evaluate medical staff and healthcare team documentation daily.
- Gather and analyze information related to documentation findings and outcomes.
- Identify opportunities for improving physician and hospital outcomes using the clinical documentation system.
- Provide or coordinate education to internal customers on compliance, coding, and clinical documentation issues.
- Act as a consultant to coders for additional information or documentation needed to assign the correct DRG.
- Coordinate, facilitate, and negotiate with others to control variances and duplication.
- Work closely with ancillary and support services.
- Document clearly and solve problems.
- Facilitate groups and implement projects as necessary.
- Adhere to ethical and professional business practices, including ACDIS code of ethics and official coding guidelines.
- Utilize professional documentation such as white papers published by ACDIS, AHIMA, and other professional organizations.
- Perform record reviews on clients of all age groups.
- Function within the scope and standards of nursing practice as outlined in the Nurse Practice Act and Administrative Rules.
Requirements
- Bachelor’s degree in nursing required. Graduate from a nationally accredited nursing program preferred (e.g., CCNE, ACEN, NLN CNEA). If no degree, seven years of equivalent work experience will be considered.
- Three years of recent clinical nursing experience required.
- Experience in case management, utilization management, and/or coding preferred.
- Unencumbered RN license with the State Board of Nursing where the practice of nursing occurs and/or multistate licensure if in a Nurse Licensure Compact (NLC) state.
- Obtain and maintain required department-specific competencies and certifications.
- Certification in Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement and Integrity (C-CDI) preferred.
Skills
- Advanced communication and interpersonal skills with all levels of internal and external customers.
- Excellent written and verbal communication, critical thinking, creative problem-solving, and conflict management skills.
- Proficient in organization, planning, and computer skills (spreadsheets, presentation programs, word processing, and Internet searching).
- Working knowledge of quality improvement theory and practice.
- Understanding of DRGs and the medical necessity process.
- Knowledge of federal, state, and other payers' regulations, requirements, and criteria.
Benefits
Sanford offers an attractive benefits package for qualifying full-time and part-time employees, including:
- Health insurance
- Dental insurance
- Vision insurance
- Life insurance
- 401(k) retirement plan
- Work/life balance benefits
- Generous time off package to maintain a healthy home-work balance
For more information about Total Rewards, visit sanfordcareers.com/benefits.
Pay
Salary range: $27.50 - $44.00 per hour.