RN-Clinical Documentation Specialist I
Entity: Medical University Hospital Authority (MUHA) · Worker Type: Employee · Worker Sub-Type: Regular · Cost Center: CC002372 SYS - System Quality and Safety
About the Role
The RN – Clinical Documentation Specialist I reports to the Manager, Clinical Documentation. Under general supervision, the RN – Clinical Documentation Specialist I conducts reviews of inpatient electronic medical records to identify missing, vague, and/or incomplete diagnoses and facilitates appropriate physician documentation to accurately reflect patient severity of illness and risk of mortality. In collaboration with the medical staff, faculty and nurse practitioners, UR, coding, Quality and the Center for Clinical Effectiveness, this role is charged with improving the quality of documentation for physicians and all caregivers.
Responsibilities
- Analyze and audit medical records concurrently to ensure clinical information is specific, accurate, clinically valid, complete, and compliant.
- Educate physicians, non-physician clinicians, nurses, and other staff to facilitate documentation 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.
- Collaborate with medical staff, faculty, nurse practitioners, utilization review, coding, Quality, and the Center for Clinical Effectiveness to improve documentation quality.
Requirements
- Bachelor's degree in nursing from an accredited school of nursing (preferred).
- At least five years of clinical nursing experience (preferred).
- Strong clinical experience and critical thinking skills.
- Extensive knowledge of patient care, 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.
Pay & Schedule
- Pay Rate Type: Salary
- Pay Grade: Health-28
- Scheduled Weekly Hours: 40