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 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.

Position Compensation Range: $73,444.80 - $117,520.00 Annual

MINIMUM REQUIREMENTS

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’ clinical experience preferably in multiple clinical areas in an ICU and as a Clinical Documentation Specialist. 

Licensure: Licensed to Practice as a Registered Nurse in the Commonwealth of Virginia or a Certified Coding Specialist Registered Health Information Technologist or Registered Health Information Administrator.   

 

PHYSICAL DEMANDS

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.

The University of Virginia, including the UVA Health System which represents the UVA Medical Center, Schools of Medicine and Nursing, UVA Physician’s Group and the Claude Moore Health Sciences Library, are fundamentally committed to the diversity of our faculty and staff.  We believe diversity is excellence expressing itself through every person's perspectives and lived experiences.  We are equal opportunity and affirmative action employers. All qualified applicants will receive consideration for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, race, religion, sex, pregnancy, sexual orientation, veteran or military status, and family medical or genetic information.