New

Clinical Documentation Specialist

The Rector & Visitors of the University of Virginia
$73,444.80 - $117,520.00 Annual
United States, Virginia, Charlottesville
1215 Lee Street (Show on map)
Sep 12, 2025
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: 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. 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.