Sanford Health ยท 1 month ago
Clinical Documentation Specialist
Sioux Falls, SD
Full-time
Onsite
Mid Level
$27.50/hr - $44/hr
3+ years expSanford Health is one of the largest and fastest-growing not-for-profit health systems in the United States. The Clinical Documentation Specialist (CDS) is responsible for ensuring comprehensive medical record documentation and facilitating communication among healthcare team members to optimize clinical treatment and outcomes.
ChildrenEducationHealth Care
Responsibilities
Communicates with providers, 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 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
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
Possesses advanced communication and interpersonal skills with all levels of internal and external customers
Demonstrates excellent written/verbal communication, critical thinking, creative problem solving, and conflict management skills
Proficient in organization and planning
Possesses strong computer skills including the use of spreadsheets, presentation programs, word processing, and Internet searching
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
Qualification
Required
Bachelor's degree in nursing required
Three years of recent clinical nursing experience required
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
Preferred
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)
Experience in case management, utilization management, and/or coding preferred
Certification in Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement and Integrity (C-CDI) preferred
Benefits
Health insurance
Dental insurance
Vision insurance
Life insurance
A 401(k) retirement plan
Work/life balance benefits
A generous time off package
Company
Sanford Health
Sanford is a healthcare company providing research, education and clinical care.
10001+ employees
H1B Sponsorship
Sanford Health has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (26)
2024 (37)
2023 (38)
2022 (51)
2021 (64)
2020 (30)
Funding
Current Stage
Late StageLeadership Team
Baier Roger
CEO
Bill Gassen
President & Chief Executive Officer
Recent News
2025-11-20
2025-11-01
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