Clinical Documentation Specialist -RN

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917412

Vidant Health

Full Time

Regular

Summary

About Vidant Medical Center

Vidant Medical Center is a 900+ bed Level-1 Trauma Center, regional referral hospital and is the flagship hospital for Vidant Health. We serve as the teaching hospital for the Brody School of Medicine at East Carolina University. Vidant Medical Center provides acute, intermediate, rehabilitation and outpatient services to more than 1.4 million people in 29 counties.  But it's in our work environment that you'll find our sense of family and closeness that permeates everything we do.

 Responsibilities 

  • Facilitates appropriate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record.
  • Actively monitors and communicates changes in patient status/plan of care
  • Facilitates concurrent performance improvement activities
  • Stays current with and conducts on-going clinical documentation management program education for new staff, including new clinical documentation specialists, physicians, nursing and allied health professionals.
  • Demonstrates acceptable level of Patient Safety and Quality Improvement behaviors
  • Collaborates effectively with departmental/program staff to achieve goals and objectives.

Minimum Requirements

  • BSN required
  • At least 4 years of clinical experience required.
  • Experience providing direct patient care to acute and chronically ill patients in inpatient settings, critical care, ED or strong med-surg experience preferred. Coding, Case Management and/or Utilization Review experience preferred.
  • An ADN degree with three additional years of clinical experience may be substituted for the BSN.
  • A Masters Degree in Nursing (MSN) may be substituted for one year of clinical expertise.
  • Prefer either CCDS or CCS.

Other Information

  • Full-time 8:00am to 4:30pm (flexible with remote option)

General Statement

It is the goal of Vidant Health and its entities to employ the most qualified individual who best matches the requirements for the vacant position.

Offers of employment are subject to successful completion of all pre-employment screenings, which may include an occupational health screening, criminal record check, education, reference, and licensure verification.

We value diversity and are proud to be an equal opportunity employer.   Decisions of employment are made based on business needs, job requirements and applicant’s qualifications without regard to race, color, religion, gender, national origin, disability status, protected veteran status, genetic information and testing, family and medical leave, sexual orientation, gender identity or expression or any other status protected by law. We prohibit retaliation against individuals who bring forth any complaint, orally or in writing, to the employer, or against any individuals who assist or participate in the investigation of any complaint.

 

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