Riverside Health System

Documentation Specialist Full Time

Location Name Riverside Regional Medical Center
Department Clin Documentation Integrity
Job ID


Riverside is currently seeking a Full Time Documentation Specialist to join our team of professionals. 


The Clinical Documentation Improvement Specialist II reports directly to the HIMS CDI Manager and System HIMS Director and is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. The CDI Specialist II assesses clinical documentation through extensive review of the medical record to provide an accurate clinical picture of the patient including severity of illness risk and resource utilization. Interacts with providers nursing staff other patient care givers and Health Information Management (HIM) coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate. The CDI specialist assists the Quality department completes data abstractions from the EMR to complete appropriate patient Quality and Core Measures conducts post discharge reconciliation for comparative analysis of CDI specialist and HIM MS/APR DRG and formulates appropriate clinical documentation clarifications to improve documentation of principal diagnosis co-morbidities present on admission (POA) quality core measures and patient safety indicators (PSI)s. The CDI Specialist II creates and conducts education sessions for the team and assists with precepting new CDI nurses.Employee may be required to work onsite in order to collaborate with other team members and clinicians per departmental policy.

Riverside began serving the Virginia Peninsula community in 1916. In 1963, Riverside moved to the present 72-acre location in Newport News on J. Clyde Morris Boulevard. A 450-bed facility, Riverside Regional Medical Center is the Virginia Peninsulas most comprehensive medical facility combining the most recent computerized medical technology with a healing environment. The Pavilion is a 250,000 sq. ft., $107 million, 3-story addition to Riverside Regional Medical Center, which opened in 2013. This acute care facility provides a regional cancer care center, the Peninsula regions only comprehensive stroke center, the areas only open-heart surgery program, the regions only Level II Trauma Center, and a cornerstone neurosciences program that includes the Chesapeake, Riverside and University of Virginia Radiosurgery Center.


EDUCATION: Nursing: Associates Degree in Nursing required or Bachelors in Nursing preferred. 


EXPERIENCE: 3+ years of Acute Care nursing required and 1 year of CDI experience is required, 3M 360 experience preferred, ICD-10-CM & ICD-10-PCS experience preferred.


LICENSURE/CERTIFICATION: Licensed RN or board eligible by the State of Virginia or compact state, CCDS (ACDIS) or CDIP (AHIMA) preferred.  


Full Time Opportunity 


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