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 HIM Coding Supervisor, 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.

Role Responsibilities:

  • Expert knowledge of medical terminology including disease/procedure classification systems such as DRGs, ICD-9-CM, CPT-4, and ICD-10
  • Knowledge of anatomy and physiology to support clinical review with physicians, record review and abstraction
  • Skilled working with Windows based applications including word processing, spreadsheet, database, and presentation software
  • Epic electronic health record, 3M Encoder, abstracting, and computerized coding software
  • In addition to office equipment such as telephone, fax machine, copy machine, computer and printer
  • Demonstrate professional responsibility in the CDS role.
  • Coordinate the logistics of the ICD-10 Clinical Documentation training environment for providers.
  • Performs chart reviews to assure that comorbidities, complications, and conditions POA are documented accurately
  • Rounds with physicians and patient care team to provide just-in-time education and support for appropriate documentation
  • Identifies barriers to accurate and complete documentation. Collaborates with providers and clinicians to design and implement electronic tools such as best practice Alerts, discharge reminders, and order sets that promote evidence based care.
  • Analyzes patterns and trends in clinical documentation at all levels of patient care. Provides feedback/education to individual clinicians, groups, and units.
  • Reviews the current OIG work plan for MS-DRG risk areas and assists HIM Coding Supervisor in maintaining a coding compliance program.
  • Utilizes and maintains the 3M CDI computer applications
  • Assists Coding Supervisor and HIM Director in monitoring required ICD-10-CM documentation compliance.
  • Remains current with relevant abstraction and coding guidelines and requirements. Participates in ongoing education.
  • Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association.


Minimum Qualifications:

  • Minimum of an Associate degree in Health Information Technology, Nursing, or other healthcare related field is required
  • A minimum of 5 years of coding experience in an acute care environment is required

Preferred Qualifications:

  • Experience in a tertiary referral center is desired
  • Experience working with clinical improvement teams is essential

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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