Clinical Documentation Specialist - Outpatient (Registered Nurse)

The Outpatient Clinical Documentation (CDS) Specialist is responsible for ensuring the accuracy, specificity, and compliance of clinical documentation in the ambulatory setting, with a strong focus on risk adjustment and HCC capture. This role would report to Pop Health but would work with the Augusta Medical Group (AMG) providers to support the providers by validating diagnoses, improving documentation quality, and enhancing outpatient workflows. Unlike traditional inpatient CDS roles, the Outpatient CDS Specialist focuses on ambulatory documentation, outpatient coding guidelines, and clinical decision support tools to ensure documentation accurately reflects patient complexity and supports value-based care initiatives.

Minimum Qualifications:

• Bachelor’s in nursing or equivalent experience.
• Licensed Registered Nurse in Virginia.
• Coding Certification with 6 months of hire if not already certified.
• Two (2) years of clinical nursing experience.
• Certification in both outpatient coding and HCC coding preferred.
• Experience with ambulatory coding and documentation preferred.
• Teaching/Education experience preferred.

Skills:

• Knowledge of health systems operations, health policy, and/or health care contracting.
• Knowledge of population health programs and concepts.
• Strong clinical judgement and analytical skills with high attention to details and strong compliance mindset.
• Advanced written and verbal communication skills with the ability to engage with providers.
• A high degree of professionalism and competency in dealing with a variety of individuals.
• Ability to teach complex concepts and maintain collaborative relationships.
• Ability to independently organize and prioritize work.
• Ability to interpret clinical data and translate it into actionable documentation guidance.
• Ability to deploy appropriate data sources, analysis methods, and effective communication of analytical results.
• Articulates and presents data, information, and ideas in a clear and concise manner.
• Creates an environment that encourages diverse opinions, recognizes differences and incorporates into process and services.

Some benefits of working at Augusta Health include:

• Retirement savings helping you to plan for your future
• Free onsite parking
• 24/7 armed security to ensure your safety
• Tuition reimbursement
• Onsite child care
• Augusta Health Fitness Reimbursement Program
• Individualized orientation with dedicated preceptor
• Onsite credit union
• Employee discounts including the cafeteria, gift shop, pharmacy, and movie tickets

Company Information:
Augusta Health is a mission-driven, independent, nonprofit, community health system located in Fishersville Virginia in Virginia’s scenic Shenandoah Valley. Augusta Health offers a full continuum of inpatient and outpatient which includes Augusta Medical Center a 255 bed inpatient facility and Augusta Medical Group which is comprised of 40 practice locations and four urgent care locations.

Equal Opportunity: Augusta Health recruits, hires and promotes qualified candidates for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, race, religion, sex (including pregnancy), sexual orientation, veteran or military discharge status, and family medical or genetic information.

Exceptional care, small town hospitality Nestled in Virginia’s beautiful Shenandoah Valley, Augusta Health is among the finest nonprofit community hospitals in America. Augusta Health opened in 1994 to continue a tradition of personalized care with small-town hospitality that began with predecessor hospitals in Staunton and Waynesboro. Today, our highly trained physicians and staff use state-of-the-art technology to provide top quality care with warmth and compassion. We offer many amenities so patients and families can be comfortable and close during difficult times. View Our Mission, Vision & Values. If you are a resident of Augusta County, Staunton, Waynesboro, or surrounding areas, you can benefit from a variety of programs we host to promote good health. If you are a dedicated healthcare professional, you will find exciting career opportunities at Augusta Health. Quick Stats for 2023 Licensed for 255 beds 124 Medical/Surgical 14 Intensive Care Unit 18 Labor and Delivery 4 Pediatric Non-traditional, Non-acute services 28 bed psychiatric unit 17 bed skilled nursing unit 8 bed rehab unit Largest local private employer Employees: 2,375+ Active Physicians: 225 APPs: 87 Volunteers: 290 Service Area: 200,000 AH Urgent Cares: 5 AH Practices: 49