Clinical Documentation Specialist RN (Registered Nurse)

Woodbridge, VA
Jan 15, 2019
Mar 20, 2019
Full Time

Sentara Northern Virginia Medical Center is hiring a full time Clinical Documentation Specialist RN (Registered Nurse).


Skills for Success
Five (5) years of recent experience in medical surgical or intensive care settings.

Position Overview
  • Responsible for concurrent review of provider in-patient medical record documentation from admission to discharge.
  • Ensuring that appropriate clinical severity of illness and risk mortality is captured for the level of service.
  • Providing education and training as needed to the medical staff.
  • Utilization of software to code documentation ICD-10 codes.
  • Note: Extensive Training is provided for this position.
Sentara Northern Virginia Medical Center Overview
Sentara Northern Virginia Medical Center is a 183-bed not-for-profit hospital located in Woodbridge, Virginia. We combine the resources of a major health system with the compassionate, personalized care of a community hospital.

We offer quiet, private rooms and high quality care focused on safety and patient satisfacition. Our clinical services inlcude advanced imaging, cancer services, cardiovascular care, emergency care, lab services, orthopedics, weight loss services, and more, all powered through Sentara eCare, a comprehensive electronic medical record system.

Sentara Overview
For more than a decade, Modern Healthcare magazine has ranked Sentara as one of the nation's top integrated healthcare systems. Our not-for-profit system proudly includes advanced imaging centers, nursing and assisted-living centers, outpatient campuses, physical therapy and rehabilitation services, home health and hospice agency, a 3,800-provider medical staff and four medical groups. In addition, we provide medical transport ambulances and Nightingale air ambulance, and we extend health insurance to 445,000 people through Optima Health, our award-winning health plan.
Sentara Benefits
As the third largest employer in Virginia, Sentara Healthcare was named by Forbes Magazine as one of America's best large employers. We offer a variety of amenities to our employees, including, but not limited to:
    Medical, Dental, and Vision InsurancePaid Annual Leave, Sick LeaveFlexible Spending AccountsRetirement funds with matching contributionSupplemental insurance policies, including legal, Life Insurance and AD&D among othersWork Perks program including discounted movie and theme park tickets among other great dealsOpportunities for further advancement within our organization
Sentara employees strive to make our communities healthier places to live. We're setting the standard for medical excellence within a vibrant, creative, and highly productive workplace. For information about our employee benefits, please visit:

Join our team! We are committed to quality healthcare, improving health every day, and provide the opportunity for training, development and growth!

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 five (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 to join this exciting growing career. Join this supportive team to review provider documentation and code using ICD-10 codes and DRG Assignment. Previous experience or knowledge in ICD-10 or MS-DRGs a plus! Must be competent with Microsoft Office, Internet, and data entry. Dependable and self-directed with the ability to successfully multitask and manage conflicting priorities.

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

keywords: RN, Registered Nurse, Clinical Documentation, Concurrent Documentation


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

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

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