Clinical Documentation Specialist RN (Registered Nurse)

Location
Williamsburg, VA
Salary
Competitive
Posted
Apr 01, 2019
Closes
May 11, 2019
Ref
122529BR
Function
Nurse
Industry
Healthcare
Hours
Full Time
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.

Qualifications

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

Experience
Required: Acute Care - 5 years

Preferred: Coding - 5 years

License
Required: Registered Nurse

Preferred: None, unless noted in the "Other" section below

Skills
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

Other
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.

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