Registered Nurse (RN) - Clinical Documentation Specialist (Part Time) Remote

University of Virginia•Charlottesville, VA

4d•Remote

About The Position

The Clinical Documentation Specialist is responsible for evaluating physician documentation using their 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. They must be self-motivated and adaptive to change. This role is primarily sedentary, involving extensive use of desktop computers, but may occasionally require travel to attend meetings and programs. The starting base rate for this role is $35.31 hourly, with individual compensation determined by qualifications, previous work experience, and/or education.

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

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.
Other duties may be assigned.