RN - Clinical Documentation Specialist

Sanford Health • Fargo, ND

9d

About The Position

The Clinical Documentation Specialist (CDS) communicates with providers, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation reflecting clinical treatment, decisions, and diagnoses for inpatients and residents. The CDS uses the hospital’s designated clinical documentation system to identify documentation opportunities related to physician and hospital outcomes, provides or coordinates education for internal customers on compliance, coding, and clinical documentation, and consults with coders when information or documentation is needed to assign the correct diagnosis-related group (DRG).

The role evaluates medical staff and healthcare team documentation day to day and gathers and analyzes information relevant to documentation findings and outcomes. The CDS contributes to a positive work environment and performs other assigned duties that support the organization. The role may include reviewing records for clients in all age groups, coordinating and negotiating with others, controlling variances and duplication, working closely with ancillary and support services, facilitating groups, and implementing projects when necessary.

The CDS works within the scope and standards of nursing practice set out in the Nurse Practice Act and applicable administrative rules in the state of practice and licensure. Professional conduct and nursing care are grounded in the American Nurses Association’s Scope and Standards of Practice and Code of Ethics for Nurses with Interpretive Statements.

Requirements

• Bachelor’s degree in nursing required; seven years of equivalent work experience may be considered if the applicant has no degree.
• Three years of recent clinical nursing experience required.
• Current, unencumbered RN license in the state where nursing practice occurs, or multistate licensure if practicing in a Nurse Licensure Compact state.
• Obtain and maintain required department-specific competencies and certifications.
• Advanced communication and interpersonal skills with internal and external customers at all levels.
• Excellent written and verbal communication, critical thinking, creative problem-solving, and conflict-management skills.
• Proficiency in organization and planning.
• Strong computer skills, including spreadsheets, presentation programs, word processing, and Internet searching.
• Working knowledge of quality improvement theory and practice.
• Working knowledge of DRGs and understanding of the medical necessity process.
• Knowledge of federal, state, and other payers’ regulations, requirements, and criteria.
• Adhere to ethical and professional business practices, including ACDIS’s code of ethics and official coding guidelines.
• Ability to coordinate and negotiate with others, document clearly, solve problems, and work closely with ancillary and support services.

Nice To Haves

• Graduation from a nationally accredited nursing program, including CCNE, ACEN, or NLN CNEA accreditation.
• Experience in case management, utilization management, and/or coding.
• Certification as a Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement and Integrity (C-CDI).

Responsibilities

• Communicate with providers, case managers, coders, and other healthcare team members to facilitate comprehensive inpatient and resident medical record documentation.
• Use the designated clinical documentation system to identify opportunities related to physician and hospital outcomes.
• Provide or coordinate education for internal customers on compliance, coding, and clinical documentation issues.
• Consult with coders when additional information or documentation is needed to assign the correct DRG.
• Evaluate medical staff and healthcare team documentation on a day-to-day basis.
• Gather and analyze information pertinent to documentation findings and outcomes.
• Review records for clients in all age groups as needed.
• Coordinate, facilitate, and negotiate with others; control variances and duplication.
• Work closely with ancillary and support services.
• Facilitate groups and implement projects when necessary.
• Perform other duties as assigned or directed to support the organization.
• Practice within applicable nursing scope and standards, laws, rules, and professional ethics.

What This Job Offers

• Job Type: Full-time