CLIN DOCUMENTATION SPEC RN

About the position

The Clinical Documentation Improvement Specialist (CDS) is a full-time role at Sentara Virginia Beach General Hospital, responsible for ensuring the accuracy and completeness of clinical documentation in patient medical records. The CDS conducts concurrent reviews of provider documentation, facilitates modifications through collaboration with healthcare providers, and utilizes coding expertise to ensure appropriate clinical severity and risk of mortality are captured. This position also involves educating medical staff on documentation practices and coding standards.

Responsibilities
? Conduct concurrent reviews of inpatient medical record documentation for new admissions and follow-up reviews until discharge.
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? Facilitate modifications to clinical documentation through interaction with providers and healthcare team members.
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? Ensure accurate clinical severity of illness and risk of mortality is captured in documentation.
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? Utilize specific software to code documentation using ICD-10 codes.
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? Provide education and training to medical staff regarding documentation and coding standards.

Requirements
? Minimum of 5 years RN - Acute Care experience in Medical/Surgical or ICU.
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? RN Diploma, Associate or Bachelor's degree required.
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? All Registered Nurses without a BSN must sign a BSN Agreement to obtain their BSN within 5 years of hire.

Nice-to-haves

Benefits
? Medical, Dental, and Vision Insurance
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? Paid Annual Leave, Sick Leave
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? Flexible Spending Accounts
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? Retirement funds with matching contribution
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? Supplemental insurance policies, including legal, Life Insurance and AD&D
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? Work Perks program including discounted movie and theme park tickets
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? Opportunities for further advancement within the organization

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