Clinical Documentation Specialist- RN

City/State

Woodbridge, VA

Overview

Work Shift

First (Days) (United States of America)

Sentara Health is seeking to hire a qualified individual to join our team as a Clinical Documentation Specialist-Registered Nurse

Position Status: Full Time, day shift

Monday- Friday, 8:00am-5:00pm

Position Summary:

The Clinical Documentation Specialist RN (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.

Minimum Requirements:

• Five (5) years of 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.

Diversity and Inclusion at Sentara

Our vision is that everyone brings the strengths that come with diversity to work with them every day. When we are achieving our vision, we have team members that feel they belong and can be their authentic selves, and our workforce is reflective of the communities we serve.

We are realizing this vision through our Diversity and Inclusion strategy, which has three pillars: A diverse and talented workforce, an inclusive and supportive workplace, and outreach and engagement with our community. We have made remarkable strides in these areas over the past several years and, as our world continues to evolve, we know our work is never done.

Our strategies focus on both structural inclusion, which looks at our organizational structures, processes, and practices; as well as behavioral inclusion, which evaluates our mindsets, skillsets, and relationships. Together, these strategies are moving our organization forward in an environment that fosters a culture of mutual respect and belonging for all.

Please visit the link below to learn more about Sentara's commitment to diversity and inclusion:

https://www.sentara.com/aboutus/mission-vision-and-values/diversity.aspx

Sentara Overview

For more than a decade, Modern Healthcare magazine has ranked Sentara Health as one of the nation's top integrated healthcare systems. That's because we are dedicated to growth, innovation, and patient safety at more than 300 sites of care in Virginia and northeastern North Carolina, including 12 acute care hospitals.

Sentara Benefits

As the third-largest employer in Virginia, Sentara Health 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 Insurance

• Paid Annual Leave, Sick Leave

• Flexible Spending Accounts

• Retirement funds with matching contribution

• Supplemental insurance policies, including legal, Life Insurance and AD&D among others

• Work Perks program including discounted movie and theme park tickets among other great deals

• Opportunities 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: Benefits

• Sentara (sentaracareers.com)

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

Please Note: The yearly Flu Vaccination is required for employment.

Note: Sentara Health offers employees comprehensive health care and retirement benefits designed with you and your family's well-being in mind. Our benefits packages are designed to change with you by meeting your needs now and anticipating what comes next. You have a variety of options for medical, dental and vision insurance, life insurance, disability, and voluntary benefits as well as Paid Time Off in the form of sick time, vacation time and paid parental leave. Team Members have the opportunity to earn an annual flat amount Bonus payment if established system and employee eligibility criteria is met.

#Indeed Monster LinkedIn RN Clinical Documentation Acute Care Experienced RN

Job Summary

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. 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.

Qualifications:

N-2YR - RN-Associate's Degree (Required), N-3YR - RN-Diploma (Non-degree) (Required)

Registered Nurse (RN) Single State

• Nursing License

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• North Dakota {+ 10 more}

Acute Care, Coding

Skills

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

Sentara Healthcare prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.

Per Clinical Laboratory Improvement Amendments (CLIA), some clinical environments require proof of education; these regulations are posted at ecfr.gov for further information. In an effort to expedite this verification requirement, we encourage you to upload your diploma or transcript at time of application.

In support of our mission "to improve health every day," this is a tobacco-free environment.