Clinical Documentation Specialist Registered Nurse (RN)
Company: Sentara Healthcare
Posted on: January 8, 2019
Overview:Sentara RMH Medical Center is hiring a full time Clinical Documentation Specialist RN (Registered Nurse).Position Overview
- Responsible for concurrent review of provider in-patient medical record documentation from admission to discharge.
- Ensuring that appropriate clinical severity of illness and risk mortality is captured for the level of service.
- Providing education and training as needed to the medical staff.
- Utilization of software to code documentation ICD-10 codes.
- NOTE: EXTENSIVE TRAINING IS PROVIDED FOR THIS POSITION.Skills for SuccessFive (5) years of current experience in adult medical surgical or adult intensive care departments.Sentara OverviewFor more than a decade, Modern Healthcare magazine has ranked Sentara as one of the nation's top integrated healthcare systems. Our not-for-profit system proudly includes advanced imaging centers, nursing and assisted-living centers, outpatient campuses, physical therapy and rehabilitation services, home health and hospice agency, a 3,800-provider medical staff and four medical groups. In addition, we provide medical transport ambulances and Nightingale air ambulance, and we extend health insurance to 445,000 people through Optima Health, our award-winning health plan. Sentara BenefitsAs the third largest employer in Virginia, Sentara Healthcare was named by Forbes Magazine as one of America's best large employers. We offer a variety of amenities to our employees, including, but not limited to:
Medical, Dental, and Vision InsurancePaid Annual Leave, Sick LeaveFlexible Spending AccountsRetirement funds with matching contributionSupplemental insurance policies, including legal, Life Insurance and AD&D among othersWork Perks program including discounted movie and theme park tickets among other great dealsOpportunities for further advancement within our organizationSentara employees strive to make our communities healthier places to live. We're setting the standard for medical excellence within a vibrant, creative, and highly productive workplace. For information about our employee benefits, please visit: Join our team! We are committed to quality healthcare, improving health every day, and provide the opportunity for training, development and growth!OtherAcute Care experience in Medical/Surgical or ICU. All Registered Nurses who do not have their BSN will be required to sign a BSN Agreement committing to successfully obtain their BSN within 5 years of hire.Responsibilities:The Clinical Documentation Improvement Specialist (CDS) is a highly knowledgeable RN who is responsible for concurrent review of provider in-patient medical record documentation. Reviews include new admissions to the facility, as well as follow up reviews in subsequent days, until discharge. Responsible for facilitation of modifications to clinical documentation through concurrent interaction with providers, and other members of the healthcare team, to ensure that appropriate clinical severity of illness and risk of mortality is captured for the level of service rendered.. The CDS is responsible for communicating to providers to ensure timely and accurate documentation and then utilizing specific software, to code the documentation utilizing ICD-10 codes. Additionally, the CDS provides education and training as needed with the medical staff. The CDS utilizes coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation in the medical record used for measuring and reporting physician/provider hospital outcome.Qualifications:Education LevelRN-Associate's Degree ORRN-Diploma (Non-degree)ExperienceRequired: Acute Care - 5 yearsPreferred: Coding - 5 yearsLicenseRequired: Registered NursePreferred: None, unless noted in the "Other" section belowSkillsRequired: Communication, Coordination, Critical Thinking, Judgment and Decision Making, Microsoft Office, Project Management, Social Perceptiveness, Speaking, Technology/Computer, WritingPreferred: None, unless noted in the "Other" section below
Keywords: Sentara Healthcare, Harrisonburg , Clinical Documentation Specialist Registered Nurse (RN), Healthcare , Harrisonburg, Virginia
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