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UVA Health

Clinical Documentation Specialist

UVA Health, Virginia, Minnesota, United States, 55792

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Clinical Documentation Specialist The Clinical Documentation Specialist is responsible for the evaluation of physician documentation utilizing their clinical expertise to ensure the patient’s 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 adaptive to change.

Responsibilities

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 assure the documentation in the medical record adequately reflects the diagnoses being treated and the procedures performed.

In addition to the above job responsibilities, other duties may be assigned.

Minimum Requirements

Education: RN, graduate of an accredited nursing program and a 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.

Compensation 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

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.

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