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RN Clinical Documentation Specialist - Document Improvement

Employer
Sanford Health
Location
Fargo, North Dakota
Salary
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Job Details


Job Title: RN Clinical Documentation Specialist | Document Improvement | Fargo

City: Fargo

State: North Dakota

Department *: * UM Document Improvement

Job Schedule: Full Time

Shift: Days

Hours Per Shift: 8 hr

JOB SUMMARY

The Clinical Documentation Specialist (CDS) communicates with providers, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients. The CDS utilizes the hospitals designated clinical documentation system to identify opportunities for physician and hospital 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, and gathers and analyzes 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. Must possess advanced communication and interpersonal skills with all levels of internal and external customers. Demonstrate excellent written/verbal communication, critical thinking, creative problem solving, and conflict management skills. Proficient in organization and planning. Possess strong computer skills including the use of spreadsheets, presentation programs, word processing, and Internet searching. Also demonstrates working knowledge of quality improvement theory and practice. Maintains working knowledge of DRGs and understanding of medical necessity process. Knowledgeable of federal, state, and other payers regulations, requirements, and criteria. Adheres to ethical and professional business practices, such as the Association of Clinical Documentation Improvement Specialists (ACDIS) code of ethics and official coding guidelines. Utilizes the appropriate professional documentation to support daily processes, including white papers published by ACDIS, American Health Information Management Association (AHIMA), and other professional organizations. May perform record reviews on clients in all age groups. Coordinates, facilitates, and negotiates with others. Controls variances and duplication. Must work closely with ancillary and support services. Ability to document clearly. Ability to solve problems. Ability to facilitate groups and implement projects when necessary.
Functions within the scope and standards of nursing practice as outlined in the Nurse Practice Act and Administrative Rules in state of practice and licensure. The Sanford Professional Nursing Practice recognizes the Scope and Standards of Practice and the Code of Ethics for Nurses with Interpretive Statements as published by the American Nurses Association as the foundation of nursing care delivery and professional conduct.

POSITION RESPONSIBILITIES

Adheres to compliance requirements in a specific area of healthcare practices. Adjusts to new or changing assignments, processes, and people. Adjusts work to accommodate the needs of group processes. Contributes to standard practices for problem-solving approaches, tools, and processes. Delivers written and oral communications that engage audience participants, respond to their questions and concerns, and produce specific outcomes and impact. Demonstrates expertise in quality assurance tools, techniques, and standards. Develops and monitors programs that integrate learning with practice opportunities. Develops and presents reports on audit findings and recommendations. Identifies and considers alternative approaches to situations or problems. Practices positive collaboration and converts difficult interactions into productive ones. Recognizes changing demands and priorities; validates changes with management.

DEPARTMENT DETAILS

Core business hours are Monday - Friday, 7 - 4.
Looking for an RN who is self-directed and able to comfortably communicate with providers, in person or via Skype.

QUALIFICATIONS

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. Certification in Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement and Integrity (C-CDI) preferred. Quality improvement/assurance personnel with nursing backgrounds can maintain their license without seeking additional hours based on roles responsibilities. Bachelors degree in nursing required. 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). If no degree, will consider seven years equivalent work experience. Additionally, three years of recent clinical nursing experience required. Experience in case management, utilization management, and/or coding 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 1-877-673-0854 or send an email to talent@sanfordhealth.org .

City: Fargo

State: North Dakota

Job Function: Nursing

Job Schedule: Full Time

Shift: Days

Req Number: req32578

Company

Sanford Health is excited to be on a journey of tremendous growth and momentum. With our vast geography, cutting-edge medicine, sophisticated research, advanced education and our own health plan, we are unique in what we do and how we do it. Through relationships built on trust and successful performance and a vision to improve the human condition, Sanford seeks to make a significant impact on health and healing. With a commitment to diversity and inclusion, our journey as an organization includes continually building on the diverse talents, experiences and beliefs of our employees, as well as the patients and communities we serve. We are proud to be from the Midwest and to impact the world. We look forward to joining with you in the journey.

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