Senior Clinical Documentation Specialist - Home & Community Based Services (HCBS) - FT Days

Sanford Health • Rapid City, SD

1d • $31 - $50

About The Position

At an advanced level, communicates with physicians, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients/residents. Utilizes designated clinical documentation system to identify opportunities for physician and 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). Responsible for the day-to-day evaluation of documentation by the medical staff and healthcare team in accordance with the designated clinical documentation system, and gathers and analyzes information pertinent to documentation findings and outcomes. Must possess advanced communication and interpersonal skills with all levels of internal and external customers. Must demonstrate excellent written/verbal communication, critical thinking, creative problem solving, and conflict management skills. Must be proficient in organization and planning. Must possess strong computer skills including the use of spreadsheets, presentation programs, word processing, and Internet searching. Must demonstrate working knowledge of quality improvement theory and practice. Must have working knowledge of DRGs and medical necessity criteria. Knowledgeable of Federal, State, and other payers' regulations, requirements, and criteria. MUST BE DUAL CERTIFIED IN OASIS AND CODING UPON HIRE.

Requirements

• Must possess advanced communication and interpersonal skills with all levels of internal and external customers.
• Must demonstrate excellent written/verbal communication, critical thinking, creative problem solving, and conflict management skills.
• Must be proficient in organization and planning.
• Must possess strong computer skills including the use of spreadsheets, presentation programs, word processing, and Internet searching.
• Must demonstrate working knowledge of quality improvement theory and practice.
• Must have working knowledge of DRGs and medical necessity criteria.
• Knowledgeable of Federal, State, and other payers' regulations, requirements, and criteria.
• MUST BE DUAL CERTIFIED IN OASIS AND CODING UPON HIRE.
• Required Certifications - OASIS (COS-C or COQS) - Home Health and Hospice (HCS-D)
• Currently holds an unencumbered RN license with the State Board of Nursing where the practice of nursing is occurring and/or possess multistate licensure if in a Nurse Licensure Compact (NLC) state.
• Obtains and subsequently maintains required department specific competencies and certifications.
• Must have a minimum of five years of clinical practice.

Nice To Haves

• Graduate from a nationally accredited nursing program preferred, including, but not limited to, Commission on Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN), and National League for Nursing Commission for Nursing Education Accreditation (NLN CNEA).
• Bachelor's degree in nursing is preferred.
• Knowledge and experience in case management, utilization management and/or Coding highly preferred.

Responsibilities

• communicates with physicians, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation
• Utilizes designated clinical documentation system to identify opportunities for physician and outcomes
• provides or coordinates education to all internal customers related to compliance, coding, and clinical documentation issues
• acts as a consultant to coders when additional information or documentation 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 in accordance with the designated clinical documentation system
• gathers and analyzes information pertinent to documentation findings and outcomes

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level