Clinical Documentation Specialist RN

The Sentara CDI Team is expanding!

We are implementing new software Aware CDI by Iodine.

Iodine experience is a plus!

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.

Acute Care experience in Medical/Surgical or ICU experience required

Education

• RN Associate Level Degree, RN Diploma or Bachelors of Nursing Degree

Certification/Licensure

• RN Nursing License Compact or Multi-State RN License

Experience

• Five (5) years Acute Care experience in Medical Surgical or ICU
• Microsoft Office
• Strong Communication Skills