Clinical Documentation Specialist, Multiple Locations

City/State

Norfolk, AL 

Overview

Work Shift

First (Days) (United States of America) 

Sentara Health is hiring Clinical Documentation Improvement Specialist (CDS) -Remote

Be a part of an excellent healthcare organization that cares about our People, Quality, Patient Safety, Service, and Integrity. Join a team that has a mission to improve health every day and a vision to be the healthcare choice of the communities that we serve!

This is a Full-Time position, fully remote, with day shift hours and great benefits!

Work Location: 
Remote opportunities available in the following states: Alabama, Delaware, Florida, Georgia,  Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota,  New Hampshire, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, West Virginia, or Wisconsin.

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.

Minimum Requirements:

• 5 years Acute Care experience in Medical/Surgical or ICU required.
• 3 or more years as a current Clinical Documentation Specialist required.
• Knowledge of ICD-10 CM & PCS, required
• CCDS or CDIP certification, preferred

Candidates must be a legal resident in the SWS States listed above.

Job Summary

Be a part of an excellent healthcare organization that cares about our People, Quality, Patient Safety, Service, and Integrity. Join a team that has a mission to improve health every day and a vision to be the healthcare choice of the communities that we serve!
This is a Full-Time position, fully remote, with day shift hours and great benefits!

Work Location:
Remote opportunities available in the following states: Alabama, Delaware, Florida, Georgia, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, New Hampshire, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, West Virginia, or Wisconsin.
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.

5 years Acute Care experience in Medical/Surgical or ICU required.
3 or more years as a current Clinical Documentation Specialist required.
Knowledge of ICD-10 CM & PCS, required
CCDS or CDIP certification, preferred 

Qualifications:

N-2YR – RN-Associate’s Degree (Required), N-3YR – RN-Diploma (Non-degree) (Required) 

Registered Nurse (RN) Multi State – Nursing License – Virginia Department of Health Professionals (VADHP) 

Acute Care, Coding 

Skills

Communication, Coordination, Critical Thinking, Judgment and Decision Making, Microsoft Office, Project Management, Social Perceptiveness, Speaking, Technology/Computer, Writing 

Sentara Healthcare prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.

Per Clinical Laboratory Improvement Amendments (CLIA), some clinical environments require proof of education; these regulations are posted at ecfr.gov for further information. In an effort to expedite this verification requirement, we encourage you to upload your diploma or transcript at time of application.

In support of our mission “to improve health every day,” this is a tobacco-free environment.