Clinical Documentation Specialist I-RN

The Role

The RN (Registered Nurse) – Clinical Documentation Specialist I reports to their respective Manager, Clinical Documentation. They conduct reviews of inpatient electronic medical records to identify missing, vague, and/or incomplete diagnoses, collaborating with providers to ensure accurate DRG (Diagnosis Related Group) assignment, patient severity of illness, and risk of mortality.

Responsibilities

• Conduct concurrent analysis and auditing of medical records to ensure clinical information is specific, accurate, clinical valid, complete, and compliant.
• Educate physicians, non-physician clinicians, nurses, and other staff on documenting clinical information that reflects the most accurate severity of illness, expected risk of mortality, hospital acquired conditions, patient safety indicators, hierarchical condition categories, and level of service rendered.

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, and knowledge of clinical measurement tools and clinical outcomes.
• Ability to establish cooperative working relationships with diverse groups and individuals, medical staff, and other health care disciplines.
• Licensure as a registered nurse by the South Carolina Board of Nursing or compact state.

Qualifications

• Mobility & Posture: Standing, sitting, walking, climbing stairs, working indoors, working outdoors (temperature extremes), working from elevated areas, kneeling, bending at the waist, twisting at the waist, squatting, reaching overhead, reaching in all directions, repetitive motion (hands/wrists/elbows/shoulders), full use of both legs, balance & coordination (lower extremities).
• Physical Requirements: Lift/carry 50 lbs. unassisted, lift/lower 50 lbs. from floor to 36”, lift up to 25 lbs. overhead, reach overhead, reach in all directions, repetitive motion (hands/wrists/elbows/shoulders), full use of both legs, balance & coordination (lower extremities), lift/carry 50 lbs. unassisted, lift/lower 50 lbs. from floor to 36”, lift up to 25 lbs. overhead, repetitive motion (hands/wrists/elbows/shoulders), full use of both legs, balance & coordination (lower extremities).

Skills

• Interpreting quality metrics.
• Participating in ICCE meetings, QAPIs, and other educational opportunities.

Benefits

Rotating shifts, overtime as required, latex-safe environment.

Pay

Salary grade Health-28, scheduled weekly hours 40, work shift.

Schedule

Rotating shifts, overtime as required, latex-safe environment.

Selected Positions

• Olfactory (smell) function: Continuous.
• Respirator use qualification: Continuous.

Work Environment & Conditions

• Effective stress management.

Equal Opportunity Employer

The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need.