Senior Clinical Documentation Specialist

Job Summary

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.

Qualifications

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.

Must have a minimum of five years of clinical practice. Knowledge and experience in case management, utilization management and / or Coding highly preferred.

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.

Benefits

Sanford Health offers an attractive benefits package for qualifying full-time and part-time employees. Depending on eligibility, a variety of benefits include health insurance, dental insurance, vision insurance, life insurance, a (k) retirement plan, work / life balance benefits, and a generous time off package to maintain a healthy home-work balance.

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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 or send an email to .

Sanford Health has a Drug Free Workplace Policy. An accepted offer will require a drug screen and pre-employment background screening as a condition of employment.