Clinical Documentation, RN
2 weeks ago
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 ecfr.gov 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.
-
Clinical Documentation, RN
2 weeks ago
Charlottesville, United States Sentara Healthcare Full timeCity/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...
-
Charlottesville, VA, United States Sentara Healthcare Full timeCity/State Charlottesville, VA Overview Work Shift First (Days) (United States of America) Sentara Health is hiring a Clinical Documentation Specialist- Registered Nurse Position Status: This is a Full Time, on-site position with day shift hours and great benefits! Our position is located in Charlottesville, VA at the beautiful Martha Jefferson...
-
Clinical Documentation Specialist RN
5 days ago
Aurora, CO, United States UC Health Full timeClinical Documentation Specialist RNApply now Save job Saved Description Clinical Documentation Specialist RN Location: Colorado. 100% remote/work-from-home position but you must reside in Colorado. Department: Clinical Documentation Integrity FTE: PRN, 0.0, 0.00 hours per pay period (2 weeks) Shift: Days Pay: $37.06 - $57.44 / hour. Pay is dependent...
-
Clinical Documentation Specialist RN
20 hours ago
Aurora, CO, United States UCHealth Full timeDescription Clinical Documentation Specialist RNLocation: Colorado. 100% remote/work-from-home position but you must reside in Colorado.Department: Clinical Documentation IntegrityFTE: PRN, 0.0, 0.00 hours per pay period (2 weeks)Shift: Days Pay: $37.06 - $57.44 / hour. Pay is dependent on applicant's relevant experienceSummary:Performs concurrent review of...
-
Clinical Documentation Specialist
4 weeks ago
Tyler, TX, United States Christus Health Full timeDescriptionSummary: The Clinical Documentation Specialist (CDS) position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The CDS will provide support and expertise through comprehensive assessment and review of inpatient medical records. The CDS will facilitate accurate DRG assignment...
-
Clinical Documentation Specialist
1 month ago
Kennewick, WA, United States Trios Health Full timeClinical Documentation Specialist coordinates and collaborates extensively with the physicians and coding staff to improve quality and completeness of documentation of care provided; Facilitates modifications to clinical documentation. Captures clinical severity which is later translated into coded data to support the level of service rendered to relevant...
-
Clinical Documentation Specialist
1 month ago
Kennewick, WA, United States Trios Health Full timeClinical Documentation Specialist coordinates and collaborates extensively with the physicians and coding staff to improve quality and completeness of documentation of care provided; Facilitates modifications to clinical documentation. Captures clinical severity which is later translated into coded data to support the level of service rendered to relevant...
-
CDI Specialist III Registered Nurse
1 month ago
Orlando, FL, United States Orlando Health Full timeCDI Specialist III Registered Nurse - Clinical Documentation - Orlando HealthPosition Summary Provides concurrent review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses or procedures. This is a hybrid role Responsibilities Conducts initial and follow-up...
-
Medical Assistant
4 weeks ago
Charlottesville, United States Alcanza Clinical Research Full timeJob DescriptionJob DescriptionDescriptionAlcanza is a growing multi-site, multi-phase clinical research company with a network of locations in MA, NH, MI, VA, SC, FL, GA, AL, MO, TX and Puerto Rico. We have established a strong presence across Phase I-IV studies and several therapeutic areas including vaccine, neurology, dermatology, psychiatry, and general...
-
CDI Specialist I Registered Nurse
3 weeks ago
Orlando, FL, United States Orlando Health Full timeCDI Specialist I Registered Nurse - Clinical Documentation - Arnold Palmer HospitalPosition Summary Provides concurrent review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses or procedures. This is a hybrid position, hospital will be Arnold Palmer Childrens...
-
CDI Specialist I Registered Nurse
1 month ago
Orlando, FL, United States Orlando Health Full timeCDI Specialist I Registered Nurse - Clinical Documentation - Arnold Palmer HospitalPosition Summary Provides concurrent review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses or procedures. This is a hybrid position, hospital will be Arnold Palmer Childrens...
-
Clinical Documentation Improvement Specialist
2 weeks ago
Lawton, OK, United States Comanche County Hospital Authority Full timeDEFINITION: Is responsible for improving the overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation through extensive concurrent interaction with physicians, nursing staff, other patient caregivers and Health Information Management coding staff to support appropriate reimbursement and clinical...
-
RN Specialist
1 week ago
Pensacola, FL, United States Sacred Heart Hospital Full timeRN Specialist - Clinical Doc ImproveDetails * Department: HIM Coding Documentation * Schedule: Full Time, 40 hrs/week, Day Shift * Hospital: Ascension Sacred Heart Pensacola * Location: Pensacola, Fl Benefits Paid time off (PTO) Various health insurance options & wellness plans Retirement benefits including employer match plans Long-term & short-term...
-
RN Clinical Supervisor
3 weeks ago
Houston, TX, United States The Pediatric Connection Full timeRN Clinical SupervisorDo you have a passion for helping medically fragile children grow and flourish to their full potential? Do you enjoy training, mentoring and coaching clinicians and caregivers? Are you looking for your next role and want a career with growth potential, not just a job? If you said yes to these questions, we are growing and we need...
-
Travel Nurse RN
2 days ago
Hillsboro, OR, United States Planet Healthcare Full timePlanet Healthcare is seeking a travel nurse RN Clinical Document Improvement Specialist for a travel nursing job in Hillsboro, Oregon.Job Description & RequirementsSpecialty: Clinical Document Improvement SpecialistDiscipline: RNStart Date: 06/17/2024Duration: 13 weeks40 hours per weekShift: 8 hours, daysEmployment Type: TravelPlanet Healthcare Job ID...
-
Clinical Research Trainee and Coordinator
6 days ago
Charlottesville, Virginia, United States University of Virginia Full timeThe University of Virginia Department of Anesthesiology within in the School of Medicine is seeking two Clinical Research Coordinators, Licensed or Non-licensed at the trainee (CRC-1) and/or coordinator (CRC-2) level. Research, both clinical and basic, is an essential part of the field of anesthesiology and is the road by which the specialty progresses. It...
-
RN Clinical Manager
5 days ago
Jacksonville, FL, United States Amedisys Inc Full timeRN Clinical ManagerOverview Full Time Day Shift Are you a highly skilled and compassionate registered nurse (RN) looking for a rewarding career in homecare as a clinical manager? If so, we invite you to join our team at Amedisys, one of the largest and most trusted home health and hospice companies in the U.S. Attractive pay $81,000 to $95,000 annually....
-
RN Clinical Manager
1 day ago
Jacksonville, FL, United States Amedisys Inc Full timeRN Clinical ManagerOverview Are you a highly skilled and compassionate registered nurse (RN) looking for a rewarding career in homecare as a clinical manager? If so, we invite you to join our team at Amedisys, one of the largest and most trusted home health and hospice companies in the U.S. Attractive pay $81,000 to $95,000 annual salary $20,000 sign on...
-
Travel Nurse RN
2 days ago
Gravesend, NY, United States Tact Staff Full timeTact Staff is seeking a travel nurse RN Clinical Document Improvement Specialist for a travel nursing job in Gravesend, New York.Job Description & RequirementsSpecialty: Clinical Document Improvement SpecialistDiscipline: RNStart Date: ASAPDuration: 13 weeks36 hours per weekShift: 12 hoursEmployment Type: TravelUse clinical knowledge to review medical charts...
-
Clinical Documentation Specialist
4 weeks ago
Irving, TX, United States Christus Health Full timeDescriptionSummary: The Clinical Documentation Specialist (CDS) position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The CDS will provide support and expertise through comprehensive assessment and review of inpatient medical records. The CDS will facilitate accurate DRG assignment...