**Location:** Avera Health **Worker Type:** Regular **Work Shift:** Day Shift (United States of America) **Pay Range:** _The pay range for this position is listed below. Actual pay rate dependent upon experience._ $30.50 - $45.75 **Position Highlights** Must be located within the Avera Footprint. Occasional travel to Sioux Falls will be required. The RN Clinical Documentation Integrity Specialist (CDIS) role performs medical record reviews, on assigned patient care units, examining and assessing all patient documentation to ensure that all information, including the illness diagnosis is accurately documented. **You Belong at Avera** **Be part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. Work where you matter.** **A Brief Overview** The RN-Clinical Documentation Specialist role is complex and requires expert knowledge of clinical care and applicable coding guidelines, as well as an ability to communicate effectively with the clinical team. The Specialist reviews assigned medical records for proper documentation as it relates to revenue cycle elements. This role collaborates with clinicians, physicians, and HIM coding staff to ensure timely and accurate documentation and provides training and education as needed. Demonstrates a willingness to maintain awareness of the business of medicine and transitional healthcare changes including but not limited to value-based purchasing, accountable care organizations and the readmission reduction program. **What you will do** + Accurately reviews the entire inpatient medical record (dictation, templates, lab, orders, and nursing notes) to determine appropriate coding utilizing: ICD-9-CM, ICD-10 (CM and PCS), DRG Grouper and APR-DRG Grouper for strategizing SOI, ROM and DRG assignment. + Utilizing advanced experience and in-depth knowledge, accurately determines the appropriate sequence of principle diagnosis code, procedure codes, MS-DRG/APR- DRG, SOI, ROM and POA reporting on Inpatient Coding Product Lines. Concurrent coding may be required on all product lines. + Familiarity with Inpatient Prospective Payment System (IPPS), including new CMS guidelines related to clinical documentation, coding and reimbursement. + Serves as a resource and provides subject matter expertise to Providers, HIM and/or coders, and other clinical entities as needed. Prompts providers/physicians/residents regarding missing, unclear, or conflicting medical record documentation and obtains additional documentation with the medical record when needed. + Devoted to ongoing, continuous learning and provides relevant updates and happenings in the business of medicine directly impacting physicians such as documentation, CDI guidelines, coding guidelines, and CDI and coding policies. + Maintains personal quality and production statistics in accordance to CDI standards. + Ability and willingness to seek out changes in healthcare reform and coding regulations then incorporate those changes into chart review and educational responsibilities. + Ability to conduct independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends, and healthcare economics. + Performs and participates in performance improvement activities, such as identifying documentation requirements for the legal record. **Essential Qualifications** The individual must be able to work the hours specified. To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge, skills, and abilities required to perform the essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions, as long as the accommodations do not cause undue hardship to the employer. **Required Education, License/Certification, or Work Experience:** + Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Integrity Specialists (ACDIS) within 3 Years + Registered Nurse (RN) - Board of Nursing An active license in the state of practice Upon Hire **Preferred Education, License/Certification, or Work Experience:** + 4-6 years Related inpatient clinical experience Knowledge of hospital revenue cycle and the electronic health record. **Expectations and Standards** + Commitment to the daily application of Avera’s mission, vision, core values, and social principles to serve patients, their families, and our community. + Promote Avera’s values of compassion, hospitality, and stewardship. + Uphold Avera’s standards of Communication, Attitude, Responsiveness, and Engagement (CARE) with enthusiasm and sincerity. + Maintain confidentiality. + Work effectively in a team environment, coordinating work flow with other team members and ensuring a productive and efficient environment. + Comply with safety principles, laws, regulations, and standards associated with, but not limited to, CMS, The Joint Commission, DHHS, and OSHA if applicable. **Benefits You Need & Then Some** Avera is proud to offer a wide range of benefits to qualifying part-time and full-time employees. We support you with opportunities to help live balanced, healthy lives. Benefits are designed to meet needs of today and into the future. + PTO front-loaded for eligible hires + Free health insurance options, for full-time single coverage on Avera High Deductible Health Plan + Up to 5% employer matching contribution for retirement + Career development guided by hands-on training and mentorship _Avera is an Equal_ _Opportunity/Affirmative_ _Action Employer_ _Minority/Female/Disabled/Veteran/Sexual_ _Orientation/Gender Identity. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-605-504-4444 or send an email to_ _talent@avera.org_ _._ At Avera, the way you are treated as an employee translates into the compassionate care you deliver to patients and team members. Because we consider health care a ministry, you can live out your faith, uphold the dignity and respect of all persons while not compromising high-quality services. Join us in making a positive impact on moving health forward. The policy of Avera to provide opportunities for all qualified employees or applicants without regard to disability and to provide reasonable accommodations for all employees or applicants who may be disabled. Avera is committed to ensuring compliance in accordance with the Americans with Disability Act. For assistance, please contact HR Now at 605-504-4444. Additional Notices: For TTY, dial 711 Avera is an Equal Opportunity/Affirmative Action Employer: Minority/Female/Disabled/Veteran/Sexual Orientation/Gender Identity.