Documentation Specialist Jobs

About The Position

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.

Benefits

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