Clinical Documentation Specialist

DATE:

03/27/2026 CLINICAL

DOCUMENTATION SPECIALIST JOB TITLE

Clinical Documentation Specialist, RN

DEPARTMENT

Coding

FLSA STATUS

Non-Exempt

REPORTS TO

Coding Manager

JOB CODE

DU - 134 POSITION SUMMARY 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. 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. Performs other duties as assigned to support the overall efforts of the organization.

ORGANIZATION RESPONSIBILITIES

Pursues professional growth through educational opportunities, professional reading, and seeking learning opportunities related to clinical documentation integrity, coding, compliance, and quality improvement. Assures cost and time efficiency of the department by maintaining productivity, reducing duplication, and promoting effective documentation practices. Promotes good interpersonal relationships through effective communication, collaboration, and conflict resolution with providers, staff, and other departments. Abides by the philosophy, mission, and objectives of Prairie Lakes Healthcare System (PLHS) and follows organization policies and procedures. Actively participates in PLHS programs related to safety, continuous quality improvement, compliance, and infection control. Maintains confidentiality of all information pertaining to patients, residents, employees, physicians, and organizational operations. Demonstrates a positive image of PLHS through effective communication and professional interactions with patients, visitors, staff, physicians, and external customers. Functions within the scope and standards of nursing practice as outlined in the Nurse Practice Act and Administrative Rules of the state of practice and licensure, and in accordance with professional nursing standards and ethical practice expectations. Adheres to ethical and professional business practices, including applicable professional standards, official coding guidelines, and recognized clinical documentation integrity resources.

JOB SPECIFICATIONS

Education and/or Experience Bachelor's degree in nursing required. Graduate from a nationally accredited nursing program preferred. If no degree, equivalent work experience may be considered. 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. Mandatory Basic and Advanced Life Support Training per policy