Sanford Health Clinical Documentation Specialist - Clinical Documentation Improve in Sioux Falls, South Dakota

Job Title: Clinical Documentation Specialist | Clinical Documentation Improve | Sioux Falls

City: Sioux Falls

State: South Dakota

Department : Clinical Documentation Improve

Job Schedule: Part Time

Shift: Days

Hours Per Shift: 8 hr

JOB SUMMARY

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. 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.

POSITION RESPONSIBILITIES

Able to work with growth and development needs of client populations in clinical area. May work with clients in all age groups and must have the ability to communicate with patients, family members and others on the health care team. Coordinates, facilitates, and negotiates with others. Fiscally responsible. Controls variances and duplication. Must work closely with ancillary and support services. Ability to document clearly. Ability to solve problems. Self motivated. Works with little direction. Ability to incorporate teaching/learning principles and adapt teaching to age group. Ability to facilitate groups and implement projects when necessary. Will be required to work primarily day hours, some weekends and holidays. Works on nursing units. May be exposed to communicable or infectious disease, hazardous materials and injury from performance of assigned duties. Is subject to multiple sensory and environmental stressors.

QUALIFICATIONS

Currently licensed with the applicable State Nursing Board and/or possess multistate licensure privileges as required by position. Certification (CCDS or C-CDI) preferred. Graduation from a NLN or AACN accredited nursing program is strongly preferred. Graduate from an approved nursing program is acceptable. Bachelor's Degree in nursing is required, or completion of the Bachelor's in Nursing within 18 months of hire. Masters in nursing is preferred, as CNL or other nursing focus area. Four (4) years of recent acute care nursing required; experience as a case manager preferred.

About Sanford Health:

At Sanford Health, we are dedicated to the work of health and healing. Every day, we show that commitment by delivering the highest quality of care to the communities we serve. We are leaders in health care and strive to provide patients across the region with convenient access to expert medical care, leading-edge technologies and world-class facilities.

In addition to strong clinical care, we are also committed to research, education and community growth. We engage in medical research to not only discover innovative ways to provide care, but also cures for common diseases. We continuously seek new ways to achieve our vision of improving the human condition here in your community, across the region and around the world.

The entire team at Sanford Health recognizes the value of healthy families and communities. We continue to gain momentum and expand our reach. Together, we can make a positive difference now, and in the future.

Sanford is an EEO/AA Employer M/F/Disability/Vet. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-877-243-1372 or send an email to talent@sanfordhealth.org .

In compliance with federal law requiring employers to verify new employees' U.S. employment eligibility, Sanford participates in E-Verify. To learn more click here for English Version at https://e-verify.uscis.gov/emp/media/resourcesContents/EverifyPosterEnglish.pdf or here for Spanish Version at https://e-verify.uscis.gov/emp/media/resourcesContents/EverifyPosterSpanish.pdf .

City: Sioux Falls

State: South Dakota

Job Function: Nursing

Job Schedule: Part Time

Shift: Days

Req Number: req17874