Clinical Documentation Specialist I

About the role

The RN (Registered Nurse) – Clinical Documentation Specialist I reports to their respective Manager, Clinical Documentation. This position conducts reviews of inpatient electronic medical records to identify missing, vague, and/or incomplete diagnoses, collaborates with providers to ensure accurate DRG (Diagnosis Related Group) assignment, patient severity of illness, and risk of mortality. Additionally, the CDI specialist risk-adjusts for expected mortality/length of stay and clinically validates key diagnoses. The role requires a baseline understanding of interpreting quality metrics and participation in relevant meetings and educational opportunities.

Responsibilities

• Conduct reviews of inpatient electronic medical records to identify missing, vague, and/or incomplete diagnoses.
• Collaborate with and facilitate appropriate provider documentation to ensure accurate DRG assignment, patient severity of illness, and risk of mortality.
• Risk adjust for expected mortality/length of stay and clinically validate key diagnoses.
• Participate in ICCE meetings, QAPIs, and other educational opportunities.

Requirements

• Bachelor's degree in nursing from an accredited school of nursing and at least five years' clinical nursing experience preferred.
• Strong clinical experience and critical thinking skills required.
• Extensive knowledge of patient care, clinical measurement tools, and clinical outcomes.
• Ability to establish cooperative working relationships with diverse groups and individuals, including medical staff and other healthcare disciplines.
• Licensure as a registered nurse by the South Carolina Board of Nursing or compact state.

Qualifications

• Mobility & Posture: Standing, sitting, walking, climbing stairs, kneeling, bending, twisting, squatting, reaching overhead, reaching in all directions, repetitive motion, full use of both legs, balance & coordination, manual dexterity & strength.
• Vision & Sensory: Corrected vision 20/40 (one or both eyes), recognition of objects (near/far), color discrimination, depth perception, peripheral vision, hearing acuity, tactile sensory function, gross motor with fine motor coordination, olfactory (smell) function, respiratory function, effective stress management, rotating shifts, overtime as required, latex-safe environment.

Skills

• Interpreting quality metrics.
• Establishing cooperative working relationships.
• Collaborating with providers.
• Risk adjusting for expected mortality/length of stay.
• Validating key diagnoses.

Benefits

• Rotating shifts.
• Overtime as required.
• Latex-safe environment.

Pay

Salary grade Health-28, scheduled weekly hours 40, work shift not specified.

Schedule

Not specified.

Benefits

• Rotating shifts.
• Overtime as required.
• Latex-safe environment.