Clinical Documentation Specialist

Clinical Documentation Specialist Job Summary Join our team and be a part of our mission to deliver accessible, high-quality, affordable, and compassionate healthcare. Prairie Lakes Healthcare System is a non-profit healthcare system serving 10 counties in northeastern South Dakota and west-central Minnesota. Our team at Prairie Lakes makes a difference in the lives of patients and their loved ones Position Summary Wage: 28.09-44.81 On‑site presence in Watertown, SD is required during the first year. This full-time position has the option to be Remote, On-site (Watertown, SD), or Hybrid after the first year. The Clinical Documentation Specialist (CDS) initiates and performs concurrent documentation review of inpatient records to identify opportunities for clarification of conditions, diagnoses, and procedures when incomplete, conflicting, or nonspecific documentation exists. This review supports accurate capture of clinical severity, level of service, medical necessity, and appropriate reimbursement through the physician query process. Key Responsibilities Communicates with providers, nursing staff, case managers, coders, and other members of the healthcare team to facilitate complete, accurate, and compliant clinical documentation in the inpatient medical record. Serves as a resource to providers by linking clinical documentation requirements, coding guidelines, and medical terminology to improve the accuracy and completeness of final code assignment. Works collaboratively with the coding department in concurrent review of the inpatient medical record to support appropriate diagnosis related group (DRG) assignment and documentation integrity. Reviews clinical documentation issues with coding staff to identify missed opportunities related to documentation specificity, coding guidelines, and reimbursement, and helps prevent future missed opportunities through education and process improvement. Demonstrates knowledge of clinical documentation standards, coding guidelines, DRGs, medical necessity requirements, and payer regulations, and provides clarification and education to providers and internal customers as needed. Monitors and evaluates the effectiveness of clinical documentation improvement efforts and concurrent review outcomes at designated intervals. Develops, analyzes, and presents reports on documentation review findings, audit results, recommendations, and outcomes to appropriate departments and committees at designated intervals. Maintains accurate and organized records of review activities, findings, queries, and outcomes in accordance with departmental, regulatory, and compliance requirements. Acts as a consultant to coding staff when additional information or documentation is needed to support correct code assignment. Facilitates collaboration among providers, coders, case managers, and ancillary/support departments to improve documentation practices, support quality outcomes, and reduce duplication and variation. Qualifications Education and/or Experience- Bachelor’s degree in nursing required. Graduate from a nationally accredited nursing program preferred. Three years of recent clinical nursing experience required. Experience in case management, utilization management, and/or coding preferred. Certificates, Licenses, Registrations- Currently holds an unencumbered RN license in the State of South Dakota, or is eligible for current licensure in the State of South Dakota, and/or possesses multistate licensure if practicing in a Nurse Licensure Compact state. Maintains required department-specific competencies and certifications. Certification as a Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement and Integrity (C-CDI) preferred. Benefits Prairie Lakes Healthcare System offers comprehensive benefits 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 403(b)-retirement plan, and generous paid time off to maintain a healthy home-work balance. Additional benefits for those qualifying include: Flexible Spending Account Employee Assistance Program for mental health Education Loan Program Community discounts including the Prairie Lakes Wellness Center Prairie Lakes Healthcare System has a Drug Free Workplace Policy. An accepted offer will require positive reference checks and pre-employment background screening as a condition of employment.