Sanford Health is seeking a dedicated and detail-oriented Clinical Documentation Specialist to join our dynamic team in Sioux Falls, South Dakota. As one of the largest and fastest-growing not-for-profit health systems in the United States, Sanford Health offers numerous opportunities for professional growth and advancement. In this role, you will play a crucial part in ensuring the accuracy and completeness of medical record documentation, which directly impacts patient care, reimbursement, and regulatory compliance.

Clinical Documentation Specialist Role Overview

The Clinical Documentation Specialist (CDS) is responsible for reviewing medical records to ensure that clinical treatment, decisions, and diagnoses are accurately and comprehensively documented for inpatients/residents. This role involves extensive communication with providers, case managers, coders, and other healthcare team members to facilitate clear and concise documentation. The CDS identifies opportunities for improvement in physician and hospital outcomes and provides education related to compliance, coding, and clinical documentation issues. As a consultant to coders, the CDS ensures that additional information or documentation is provided to assign the correct diagnosis-related group (DRG). This position requires strong analytical, communication, and problem-solving skills, as well as a thorough understanding of medical terminology, coding guidelines, and healthcare regulations.

A Day in the Life of a Clinical Documentation Specialist

A typical day for a Clinical Documentation Specialist at Sanford Health involves a variety of tasks aimed at improving the quality and accuracy of medical record documentation. Here’s a glimpse into what you can expect:

1. Morning Review: Start the day by reviewing medical records for pediatric and NICU patient populations, identifying discrepancies or areas needing clarification.
2. Collaboration: Communicate with physicians and other healthcare team members to discuss documentation issues and gather additional information.
3. Documentation Analysis: Analyze documentation to ensure it accurately reflects the patient's clinical condition, treatment, and outcomes.
4. Education: Provide education and training to healthcare staff on clinical documentation requirements and best practices.
5. Coding Consultation: Consult with coders to provide additional information needed for accurate DRG assignment.
6. Quality Improvement: Participate in quality improvement initiatives to enhance the overall documentation process.
7. Compliance: Ensure compliance with federal, state, and payer regulations.
8. Afternoon Review: Continue reviewing medical records, focusing on complex cases and identifying potential areas for improvement.
9. Meetings: Attend team meetings to discuss ongoing projects, share insights, and collaborate on solutions.
10. Documentation: Document all interactions and findings in the designated clinical documentation system.

Why Sioux Falls, South Dakota?

Sioux Falls is a vibrant and growing city that offers a high quality of life at an affordable cost. Known for its friendly atmosphere, excellent schools, and numerous recreational opportunities, Sioux Falls is an ideal place to live and work. The city boasts a thriving job market, diverse cultural scene, and a strong sense of community. With beautiful parks, bike trails, and family-friendly attractions, Sioux Falls provides a perfect balance between urban amenities and outdoor adventures. Living in Sioux Falls also means enjoying a lower cost of living compared to many other cities in the United States, making it an attractive option for those looking to build a career and raise a family.

Career Path for Clinical Documentation Specialists at Sanford Health

Sanford Health is committed to providing its employees with opportunities for professional growth and advancement. The career path for a Clinical Documentation Specialist can lead to various roles within the organization. Here are a few potential career trajectories:

• Senior Clinical Documentation Specialist: Take on more complex cases and provide mentorship to junior CDS staff.
• Clinical Documentation Lead: Oversee a team of CDS professionals and manage documentation improvement initiatives.
• Clinical Documentation Manager: Lead a department responsible for clinical documentation improvement across multiple facilities.
• Compliance Officer: Ensure adherence to healthcare regulations and guidelines.
• Quality Improvement Specialist: Focus on improving the quality of patient care through data analysis and process improvement.
• Auditor: Conduct internal audits to ensure documentation accuracy and compliance.

Salary and Benefits

Sanford Health offers a competitive salary and comprehensive benefits package to attract and retain top talent. The salary range for a Clinical Documentation Specialist in Sioux Falls, South Dakota, typically falls between $55,000 and $85,000 per year, depending on experience and qualifications. In addition to a competitive salary, Sanford Health provides a robust benefits package, including:

• Health Insurance: Comprehensive medical, dental, and vision coverage.
• Paid Time Off: Generous paid time off (PTO) and holiday pay.
• Retirement Plan: 401k with employer match to help you save for retirement.
• Life Insurance: Life insurance and disability coverage to protect you and your family.
• Flexible Spending Accounts: Flexible spending accounts (FSA) or health savings accounts (HSA) to help you save on healthcare expenses.
• Employee Assistance Program: Employee assistance program (EAP) to provide support and resources for personal and professional challenges.
• Professional Development: Opportunities for professional development and continuing education assistance.
• Tuition Reimbursement: Tuition reimbursement program to help you advance your education.
• Employee Discounts: Employee discount program to save on various products and services.
• Wellness Programs: Wellness programs and resources to promote a healthy lifestyle.

Sanford Health Culture

Sanford Health is committed to creating a supportive and collaborative work environment where employees feel valued and empowered. The organization fosters a culture of teamwork, innovation, and continuous improvement. Employees are encouraged to share their ideas and contribute to the overall success of the organization. Sanford Health also places a strong emphasis on employee well-being and provides resources to help employees maintain a healthy work-life balance. The organization is dedicated to providing high-quality patient care and is committed to making a positive impact on the communities it serves.

How to Apply

If you are a motivated and detail-oriented professional with a passion for improving clinical documentation, we encourage you to apply for the Clinical Documentation Specialist position at Sanford Health. To apply, please follow these steps:

1. Visit the Sanford Health careers website.
2. Search for the Clinical Documentation Specialist position in Sioux Falls, South Dakota.
3. Review the job description and requirements.
4. Click on the "Apply Now" button.
5. Create an account or log in to your existing account.
6. Complete the online application form.
7. Upload your resume and cover letter.
8. Submit your application.

We look forward to reviewing your application and considering you for this exciting opportunity!

Frequently Asked Questions (FAQ)

1. What qualifications are required for this position?
   A Registered Nurse (RN) or other clinical licensure is preferred, or equivalent experience in a healthcare field. Experience in clinical documentation improvement, coding, or case management is required.
2. What are the key responsibilities of a Clinical Documentation Specialist?
   Key responsibilities include reviewing medical records, collaborating with healthcare team members, providing education, and ensuring compliance with coding guidelines.
3. What skills are important for success in this role?
   Important skills include strong analytical, communication, and problem-solving abilities, as well as a thorough understanding of medical terminology and coding guidelines.
4. What is the work schedule for this position?
   The position is four days per week, with eight-hour workdays and flexibility in start and end times. There are no nights, weekends, or holidays.
5. Is remote work an option for this position?
   Training is on-site, but remote work may be considered after one year or possibly sooner when proficient in the job role.
6. What is the salary range for this position?
   The salary range typically falls between $55,000 and $85,000 per year, depending on experience and qualifications.
7. What benefits does Sanford Health offer?
   Sanford Health offers a comprehensive benefits package, including health insurance, paid time off, retirement plan, life insurance, and more.
8. What is the culture like at Sanford Health?
   Sanford Health fosters a supportive and collaborative work environment with a focus on teamwork, innovation, and continuous improvement.
9. What career advancement opportunities are available?
   Career paths can lead to roles such as Senior Clinical Documentation Specialist, Clinical Documentation Lead, Clinical Documentation Manager, and more.
10. How do I apply for this position?
    Visit the Sanford Health careers website, search for the Clinical Documentation Specialist position in Sioux Falls, South Dakota, and follow the application instructions.