Clinical Documentation Specialist- RN

3 weeks ago


Vaughan ON, Canada Sentara Full time

Work Shift
First (Days) (United States of America) 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. 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. N-2YR - RN-Associate's Degree (Required), N-3YR - RN-Diploma (Non-degree) (Required)Registered Nurse License (RN) - Alabama, Registered Nurse License (RN) - Alabama, Registered Nurse License (RN) - Arizona, Registered Nurse License (RN) - Arkansas, Registered Nurse License (RN) - Colorado, Registered Nurse License (RN) - Delaware, Registered Nurse License (RN) - Florida, Registered Nurse License (RN) - Georgia, Registered Nurse License (RN) - Idaho, Registered Nurse License (RN) - Indiana, Registered Nurse License (RN) - Iowa, Registered Nurse License (RN) - Kansas, Registered Nurse License (RN) - Kentucky, Registered Nurse License (RN) - Louisiana, Registered Nurse License (RN) - Maine, Registered Nurse License (RN) - Maryland, Registered Nurse License (RN) - Mississippi, Registered Nurse License (RN) - Missouri, Registered Nurse License (RN) - Montana, Registered Nurse License (RN) - Nebraska, Registered Nurse License (RN) - New Hampshire, Registered Nurse License (RN) - New Jersey, Registered Nurse License (RN) - New Mexico, Registered Nurse License (RN) - North Carolina, Registered Nurse License (RN) - North Dakota {+ 10 more}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.
these regulations are posted at for further information. In support of our mission "to improve health every day," this is a tobacco-free environment.
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