Clinical Documentation Specialist

Clinical Documentation Specialist

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.

Responsibilities include:

• 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 which is used for measuring and reporting physician and hospital outcomes.
• Communicate with members of the medical staff on an ongoing basis to assure 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.

Minimum Requirements

Education: RN, graduate of accredited nursing program and Bachelor of Science in Nursing required within 5 years of hire.

Experience: A minimum of three years of experience as a Clinical Documentation Specialist is required. Clinical experience in multiple areas, particularly in the ICU, is preferred.

Licensure: Licensed to Practice as a Registered Nurse in the Commonwealth of Virginia.

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

Position Compensation Range: $63,945.00 - $127,890.00 Annual

Benefits:

• Comprehensive Benefits Package: Medical, Dental, and Vision Insurance
• Paid Time Off, Long-term and Short-term Disability, Retirement Savings
• Health Saving Plans, and Flexible Spending Accounts
• Certification and education support
• Generous Paid Time Off

UVA Health is a world-class Magnet Recognized academic medical center and health system with a level 1 trauma center. 2023-2024 U.S. News & World Report "Best Hospitals" guide rates UVA Health University Medical Center as "High Performing" in 5 adult specialties and 14 conditions/procedures. We are one of 70 National Cancer Institute designated cancer centers. UVA Health Children's is named by 2023-2024 U.S. News & World Report as the best children's hospital in Virginia with 9 specialties ranked among the best in the nation. Our footprint also encompasses 3 community hospitals and an integrated network of primary and specialty care clinics throughout Charlottesville, Culpeper, Northern Virginia, and beyond. The University of Virginia is an equal opportunity employer. All interested persons are encouraged to apply, including veterans and individuals with disabilities. Click here to read more about UVA's commitment to non-discrimination and equal opportunity employment.