Clinical Documentation Specialist RN
Clinical Documentation Specialist RN
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Job Description
City/State
Norfolk VAWork Shift
First (Days)Overview:
The Sentara CDI Team is expanding!
We are implementing new software Aware CDI by Iodine.
Iodine experience is a plus!
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 experience required
Education
- RN Associate Level Degree RN Diploma or Bachelors of Nursing Degree
Certification/Licensure
- RN Nursing License Compact or Multi-State RN License
Experience
- Five (5) years Acute Care experience in Medical Surgical or ICU
- Microsoft Office
- Strong Communication Skills
Legal Resources Plan
Colleagues have the opportunity to earn an annual discretionary bonus ifestablished system and employee eligibility criteria is met.
Sentara Health is an equal opportunity employer and prides itself on the diversity and inclusiveness of its close to an almost 30000-member workforce. Diversity inclusion and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.
In support of our mission to improve health every day this is a tobacco-free environment.
For positions that are available as remote work Sentara Health employs associates in the following states:
Alabama Delaware Florida Georgia Idaho Indiana Kansas Louisiana Maine Maryland Minnesota Nebraska Nevada New Hampshire North Carolina North Dakota Ohio Oklahoma Pennsylvania South Carolina South Dakota Tennessee Texas Utah Virginia Washington West Virginia Wisconsin and Wyoming.
Required Experience:
Unclear Seniority
Employment Type
Full-Time
