Clinical Documentation Specialist

16 hours ago


Virginia Beach, Virginia, United States Sentara Healthcare Full time
Job Summary

The Clinical Documentation Specialist 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.

Requirements:

Minimum of 5 years RN - 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. RN Diploma, Associate or degree required.

Benefits:

Sentara Healthcare offers a comprehensive benefits package, including medical, dental, and vision insurance, life insurance, disability, and voluntary benefits. Team Members have the opportunity to earn an annual flat amount Bonus payment if established system and employee eligibility criteria is met.

About Sentara Healthcare:

Sentara Healthcare is a tobacco-free environment and is committed to diversity and inclusion. Our vision is that everyone brings the strengths that come with diversity to work with them every day. When we are achieving our vision, we have team members that feel they belong and can be their authentic selves, and our workforce is reflective of the communities we serve. We are realizing this vision through our Diversity and Inclusion strategy, which has three pillars: A diverse and talented workforce, an inclusive and supportive workplace, and outreach and engagement with our community. We have made remarkable strides in these areas over the past several years and, as our world continues to evolve, we know our work is never done. Our strategies focus on both structural inclusion, which looks at our organizational structures, processes, and practices; as well as behavioral inclusion, which evaluates our mindsets, skillsets, and relationships. Together, these strategies are moving our organization forward in an environment that fosters a culture of mutual respect and belonging for all.

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