Clinical Documentation, RN

Sentara
United States, Virginia, Norfolk
April 24, 2024
City/State Charlottesville, VA Overview Work Shift First (Days) (United States of America) Job Summary The Clinical Documentation Improvement Specialist (CDS) is a highly knowledgeable RN who is responsible for concurrent review of provider in-patient medical record documentation. Reviews include new admissions to the facility, as well as follow up reviews in subsequent days, until discharge. Responsible for facilitation of modifications to clinical documentation through concurrent interaction with providers, and other members of the healthcare team, to ensure that appropriate clinical severity of illness and risk of mortality is captured for the level of service rendered.. The CDS is responsible for communicating to providers to ensure timely and accurate documentation and then utilizing specific software, to code the documentation utilizing ICD-10 codes. Additionally, the CDS provides education and training as needed with the medical staff. The CDS utilizes coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation in the medical record used for measuring and reporting physician/provider hospital outcome. Acute Care experience in Medical/Surgical or ICU. All Registered Nurses who do not have their BSN will be required to sign a BSN Agreement committing to successfully obtain their BSN within 5 years of hire. Qualifications: N-2YR - RN-Associate's Degree (Required), N-3YR - RN-Diploma (Non-degree) (Required) Registered Nurse (RN) Single State - Nursing License - North Carolina, Registered Nurse (RN) Single State - Nursing License - Virginia Department of Health Professionals (VADHP), Registered Nurse License (RN) - Nursing License - Compact/Multi-State License Acute Care, Coding Skills Communication, Coordination, Critical Thinking, Judgment and Decision Making, Microsoft Office, Project Management, Social Perceptiveness, Speaking, Technology/Computer, Writing Sentara Healthcare prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves. Per Clinical Laboratory Improvement Amendments (CLIA), some clinical environments require proof of education; these regulations are posted at for further information. In an effort to expedite this verification requirement, we encourage you to upload your diploma or transcript at time of application. In support of our mission "to improve health every day," this is a tobacco-free environment.