Clinical Documentation Specialist

University of Virginia

3d

About The Position

The Clinical Documentation Specialist is responsible for the evaluation of physician documentation utilizing their clinical expertise to ensure the patients’ severity of illness is accurately portrayed in the medical record for specificity of coding and increased coding accuracy. They provide guidance to the physicians nursing and ancillary staff on clinical documentation best practices. They must be self motivated and be adaptive to change. 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. In addition to the above job responsibilities, other 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
• ensure the patients’ severity of illness is accurately portrayed in the medical record
• provide guidance to the physicians nursing and ancillary staff on clinical documentation best practices
• 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.

Benefits

• Comprehensive Benefits Package: Medical, Dental, and Vision Insurance
• Paid Time Off, Long-term and Short-term Disability, Retirement Savings
• Health Saving Plans, and Flexible Spending Accounts
• Certification and education support
• Generous Paid Time Off

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees