Clinical Documentation Specialist Rn (Registered Nurse): 106598 Br
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Posted by: Sentara on Dec 04, 2018


Location:

Norfolk, VA

Job Description:

Overview
Sentara Norfolk General Hospital is hiring a full time Clinical Documentation Specialist RN (Registered Nurse).
UP TO A $10,000 SIGN ON BONUS PAID TO CANDIDATE SUCCESSFULLY HIRED.
Skills for Success
Five (5) years of recent experience in medical surgical or intensive care settings.
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. Sentara Norfolk General Hospital Overview
Sentara Norfolk General Hospital (SNGH) is the regions first Magnet Hospital. SNGH is a 525-bed medical center, and home to the area's only Level I Trauma Center, Burn Trauma Unit, and Nationally Ranked Heart Program. In addition to a first rate heart program, the hospital is home to Nightingale Regional Air Ambulance and several dedicated facilities an specialized services.
Sentara Overview
For 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 Benefits
As 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 Insurance Paid Annual Leave, Sick Leave Flexible Spending Accounts Retirement funds with matching contribution Supplemental insurance policies, including legal, Life Insurance and AD&D among others Work Perks program including discounted movie and theme park tickets among other great deals Opportunities for further advancement within our organization Sentara 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: https://www.sentaracareers.com/explore-sentara/benefits/
Join our team! We are committed to quality healthcare, improving health every day, and provide the opportunity for training, development and growth!

Other
Acute 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 five (5) years of hire.
Preferred candidates with Acute Care experience will be on Medical/Surgical units or in an ICU unit. Flexible hours are available. Extensive training and orientation will be provided to staff nurses. Utilize your nursing knowledge and experience and join this exciting and growing career. Join our supportive team to review provider documentation and code using ICD-10 codes and DRG assignment. Previous experience or knowledge in ICD-10 or MS-DRGs a plus!
Must be competent in Microsoft Office, internet and data entry. Dependable and self-directed with the ability to successfully multitask and mange conflicting priorities.
To learn more about Clinical Documentation Improvement, and the job of Clinical Documentation Specialist, please visit our professional organization's website at www.acdis.org
Keywords: Clinical Documentation, RN, Registered Nurse, Concurrent Documentation

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 Level
RN-Associate's Degree OR
RN-Diploma (Non-degree)
Experience
Required: Acute Care - 5 years
Preferred: Coding - 5 years
License
Required: Registered Nurse
Skills
Required: Communication, Coordination, Critical Thinking, Judgment and Decision Making, Microsoft Office, Project Management, Social Perceptiveness, Speaking, Technology/Computer, Writing

HR. Website URL:

http://www.sentaracareers.com/career-opportunities/

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About Sentara Healthcare

Sentara Healthcare is one of the most progressive and integrated health care organizations in the nation, located mainly in Southeast Virginia and Northern North Carolina with additional sites in Charlottesville, Covington, Harrisonburg and Woodbridge, VA. Sentara operates more than 100 care giving sites, including 12 acute care hospitals including 7 in Hampton Roads, 1 in Northern Virginia and 2 in the Blue Ridge Region, 1 in Southwestern Virginia and 1 in Northeastern North Carolina, outpatient care facilities, nursing centers, assisted living centers, advanced imaging centers and about 380 primary care and multi-specialty physicians. Sentara also offers a full range of award-winning health coverage plans, home health and hospice services, physical therapy and rehabilitation services, including Nightingale - the region’s first air ambulance service. Sentara Healthcare is an acknowledged leader in patient safety and quality innovation. Founded in 1888 as the Retreat for the Sick in Norfolk, Virginia, Sentara has ranked for more than a decade among the nation's top integrated healthcare systems by Modern Healthcare magazine and is the #1 most integrated health care system for two consecutive years. We invite you to share our Vision. To be the healthcare of choice in the communities we serve.

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