RN - Registered Nurse - Clinical Documentation Specialist - Thief River Falls - FT Weekdays at Sanford Health summary:
The Clinical Documentation Specialist (CDS) at Thief River Falls plays a crucial role in enhancing the accuracy of clinical documentation within the hospital's system. By providing education and consultation to medical staff and coders, the CDS ensures compliance with regulations while evaluating documentation to optimize hospital outcomes. The role requires advanced communication skills and knowledge of coding practices, facilitating a collaborative work environment to uphold the standards of nursing practice.
The CDS utilizes the hospital's 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 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.
Keywords:
Registered Nurse, Clinical Documentation Specialist, Healthcare Documentation, Compliance and Coding, Patient Care, Medical Records, Nursing Practice, Quality Improvement, Health Information Management, Interpersonal Skills
