RN - Clinical Documentation Specialist

Sanford Health • Fargo, ND

22h • $28 - $44

About The Position

The Clinical Documentation Specialist (CDS) works with providers, case managers, coders, and other healthcare team members to support comprehensive inpatient and resident medical record documentation that reflects clinical treatment, decisions, and diagnoses. The role evaluates documentation, identifies opportunities related to physician and hospital outcomes, and gathers and analyzes information about documentation findings and outcomes.

The CDS uses the hospital’s designated clinical documentation system, provides or coordinates education on compliance, coding, and clinical documentation, and consults with coders when more information is needed to assign the correct diagnosis-related group (DRG). The position requires strong communication, critical thinking, problem-solving, conflict-management, organizational, and computer skills, along with working knowledge of quality improvement, DRGs, medical necessity, and payer regulations. The CDS follows applicable nursing practice standards, professional ethics, and official coding guidelines. Record reviews may include clients of all age groups.

Requirements

• Bachelor’s degree in nursing; if no degree, seven years of equivalent work experience will be considered.
• Three years of recent clinical nursing experience.
• Current, unencumbered RN license with the State Board of Nursing where nursing practice occurs, or multistate licensure if in a Nurse Licensure Compact state.
• Advanced communication and interpersonal skills with internal and external customers.
• 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.
• Adherence to ethical and professional business practices, including applicable ACDIS ethics and official coding guidelines.
• Ability to coordinate, facilitate, and negotiate with others; control variances and duplication; document clearly; solve problems; and facilitate groups or implement projects when necessary.
• Practice within the scope and standards of nursing practice in the applicable state and licensure.

Nice To Haves

• Graduate of a nationally accredited nursing program, including CCNE, ACEN, or NLN CNEA.
• 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 medical record documentation.
• Use the hospital’s 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 documentation by the medical staff and healthcare team as part of day-to-day work.
• Gather and analyze information pertinent to documentation findings and outcomes.
• Coordinate, facilitate, and negotiate with others, and work closely with ancillary and support services.
• Control variances and duplication, document clearly, solve problems, and facilitate groups or implement projects when necessary.
• Perform other duties as assigned or directed to support the organization.
• Maintain required department-specific competencies and certifications and practice within applicable nursing standards.

What This Job Offers

• Job Type: Full-time