Clinical Documentation Specialist RN -Concurrent Documentation
Shift: Full Time, days
- Clinical Documentation RN positions across the Sentara system
- Highly skilled Registered Nurses with five years' or more recent Acute Care training
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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.
RN-Associate's Degree OR
Required: Acute Care - 5 years
Preferred: Coding - 5 years
Required: Registered Nurse
Required: Communication, Coordination, Critical Thinking, Judgment and Decision Making, Microsoft Office, Project Management, Social Perceptiveness, Speaking, Technology/Computer, Writing
Acute Care experience in Medical/Surgical or ICU. 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 24 months of hire and successfully obtaining their BSN within 5 years of hire.
keywords: RN, Registered Nurse, Clinical Documentation, Concurrent Documentation