Clinical Documentation Specialist RN

Expiring today

Virginia Beach, VA
Jan 02, 2018
May 21, 2018
Healthcare, Other
Full Time
Job Description: 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.

Education Level
RN-Associate's Degree OR
RN-Diploma (Non-degree)

Required: Acute Care - 5 years

Preferred: Coding - 5 years

Required: Registered Nurse

Preferred: None, unless noted in the “Other” section below

Required: Communication, Coordination, Critical Thinking, Judgment and Decision Making, Microsoft Office, Project Management, Social Perceptiveness, Speaking, Technology/Computer, Writing

Preferred: None, unless noted in the “Other” section below

All new RN's who do not have their BSN will be required to sign a BSN Agreement committing to enrollment in an accredited RN to BSN program within 23 months of hire and successfully obtaining their BSN within 5 years of hire.

Preferred candidates with Acute Care experience would be on Medical/Surgical nursing units or in ICU. Flexible hours available. Extensive training and orientation provided to staff nurses. Utilize your nursing knowledge and experience to join this exciting and growing career.

Join this supportive team to review provider documentation and code using ICD-10 and DRG assignment. Previous experience or knowledge in ICD-10 or MS-DRGs a plus! Must be competent with Microsoft Office, internet and date entry. Dependable and self-directed professional with the ability to successfully multi-task and manage conflicting priorities.

To learn more about Clinical Documentation Improvement, and the job of Clinical Documentation Specialist, please visit our organization's website at

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