Clinical Documentation Specialist Job

Full Job Title: Clinical Documentation Specialist- Day 80 hours

Job Number: 17005138

Facility: SSM Health St. Clare Hospital - Baraboo

Location: Baraboo, WI

Schedule: Full Time

Hours: 7am - 330pm


Role Purpose:

Under the general direction of the Director of Quality, Risk Management, and HIM and the direct supervision of the Regional Manager of Clinical Documentation Specialists. The Clinical Documentation Specialist (CDS) is responsible for developing and implementing systems designed to improve the overall quality and completeness of the medical record through concurrent and retrospective analytic processes. The individual in this role advises members of the medical and nursing staffs and other clinicians regarding complete and accurate documentation in order to promote an accurate interdisciplinary record or care, as well as the capture of clinical severity of individual patients and populations.

Role Responsibilities:

· Conducts timely initial and follow-up reviews of the inpatient medical record, during the patient stay, for opportunities to clarify the documentation for accurate and complete reflection of the severity of illness of the patient.

· Provides concurrent review of the clinical documentation in the medical record.

· Performs a thorough chart review to identify comorbidities/complications, and documents these appropriately within the concurrent DRG worksheet.

· Demonstrates an understanding of the importance of and makes an effort to capture all appropriate secondary diagnoses in order to accurately capture severity of illness and risk of mortality for risk-adjusted internal and publicly reported measures.

· Queries the medical staff and other caregivers as necessary via written/verbal communication to obtain accurate and complete physician documentation that supports the severity of illness and risk of mortality of the patient.

· Follows up on unanswered queries during the patient stay, as needed.

· Demonstrates creativity and enthusiasm while pursuing the goals of the department and the organization.

· Conducts education of the medical staff, informally and formally, on the benefits of accurate and complete documentation to assist in maintain physician buy-in and support.

· Provide feedback to the medical staff stressing that the documentation improvement program is fundamental to accurate risk adjustment for internal and publicly reported measures.

· Review process and productivity reports and coordinate with Lead to adjust priorities and approach to reviews, as needed.


Minimum Requirements:

  • Bachelor's Degree required.
  • Current licensure as a Registered Nurse in the State of Wisconsin.
  • A minimum of 5 years of adult acute care nursing experience required.

· Knowledge of care delivery documentation systems and related medical record documents. Knowledge of medical terminology including disease/procedure classification systems such as DRGs, CPT-4, and ICD-10. Knowledge of anatomy and physiology to support clinical review with physicians, record review and abstraction. Knowledge of age-specific needs and the elements of disease processes and related procedures.

· Excellent written and verbal communication skills and critical thinking skills. Assertive and collaborative with the demonstrated skills to facilitate ongoing physician communication. Ability to work independently in a time-oriented environment. Experience with an electronic medical record system preferably Epic.

Preferred Requirements:

  • Bachelor of Science in Nursing preferred.
  • Experience working with clinical improvement teams is essential.
  • RN with additional CDIP or Coding credential is desired but not required for the position.

St. Clare Hospital – Baraboo –

Our 100-bed St. Clare Hospital is a nationally recognized leader in rural health care in south-central Wisconsin. St. Clare offers acute care, as well as a wide range of other services including chemical dependency treatment, hemodialysis, radiation oncology and a free-standing hospice facility. Additional urgent care services are available at campus locations in the surrounding communities of Wisconsin Dells and Lake Delton.

SSM Health is an Equal Opportunity and Affirmative Action Employer. Qualified applicants are considered for employment without regard to race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity, or any other characteristic protected by law. Learn More »

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