Clinical Documentation Specialist
Job ID: R0039079 | Medical Coding | Full Time | Charlottesville, VA
The Clinical Documentation Specialist is responsible for the evaluation of physician documentation utilizing their clinical expertise to ensure the patients' severity of illness is accurately portrayed in the medical record for specificity of coding and increased coding accuracy. They provide guidance to the physicians, nursing, and ancillary staff on clinical documentation best practices. They must be self-motivated and be adaptive to change.
  • Responsible for the day-to-day evaluation of inpatient documentation in accordance with the Clinical Documentation Program requirements.
  • Ensures the accuracy and completeness of clinical information that is used for measuring and reporting physician and hospital outcomes.
  • Communicates with members of the medical staff on an ongoing basis to ensure the documentation in the medical record adequately reflects the diagnoses being treated and the procedure performed.
  • In addition to the above job responsibilities, other duties may be assigned.

Position Compensation Range: $65,208.00 - $104,332.80 Annually

  • Education: Associate's degree. If RN, graduate of accredited nursing program and Bachelor of Science in Nursing required within 5 years of hire.
  • Experience: 3 years of clinical experience, preferably in multiple clinical areas or in an ICU and as a Clinical Documentation Specialist.
  • Licensure: Licensed to practice as a registered nurse in the Commonwealth of Virginia, a Certified Coding Specialist, Registered Health Information Technologist, or Registered Health Information Administrator.

This is primarily a sedentary job involving extensive use of desktop computers. The job does occasionally require walking some distance to attend meetings and programs.

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Charlottesville, VA
Charlottesville, VA 22903

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