Clinical Documentation Specialist

UVA Health

61d•Onsite

About The Position

The Clinical Documentation Specialist is responsible for evaluating physician documentation using clinical expertise to ensure patients' severity of illness is accurately portrayed in the medical record for specificity of coding and increased coding accuracy. They provide guidance to physicians, nursing, and ancillary staff on clinical documentation best practices. The role requires self-motivation and adaptability to change. The specialist will be responsible for the day-to-day evaluation of inpatient documentation in accordance with Clinical Documentation Program requirements, ensuring the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes. They will communicate with medical staff on an ongoing basis to ensure documentation adequately reflects diagnoses being treated and procedures performed. Additional duties may be assigned.

Requirements

RN, graduate of accredited nursing program and Bachelor of Science in Nursing required within 5 years of hire.
A minimum of three years of experience as a Clinical Documentation Specialist is required.
Licensed to Practice as a Registered Nurse in the Commonwealth of Virginia.

Nice To Haves

Clinical experience in multiple areas, particularly in the ICU, is preferred.

Responsibilities

Evaluation of physician documentation utilizing clinical expertise to ensure patients' severity of illness is accurately portrayed in the medical record for specificity of coding and increased coding accuracy.
Provide guidance to physicians, nursing, and ancillary staff on clinical documentation best practices.
Responsible for the day-to-day evaluation of inpatient documentation in accordance with the Clinical Documentation Program requirements.
Ensures the accuracy and completeness of clinical information which is used for measuring and reporting physician and hospital outcomes.
Communicate with members of the medical staff on an ongoing basis to assure the documentation in the medical record adequately reflects the diagnoses being treated and the procedure performed.