Clinical Documentation Specialist I - RN-1
About The Position
The RN (Registered Nurse) – Clinical Documentation Specialist I report to their respective Manager, Clinical Documentation. Under general supervision, the RN – Clinical Documentation Specialist I conduct reviews of inpatient electronic medical records to identify missing, vague, and/or incomplete diagnoses and collaborate with and facilitate appropriate provider documentation to accurately reflect appropriate DRG (Diagnosis Related Group) assignment, patient severity of illness and risk of mortality. In addition, the CDI (Clinical Documentation Integrity) specialist risk adjusts for expected mortality/length of stay and clinically validates key diagnoses. The RN – Clinical Documentation Specialist I is responsible for a baseline understanding of interpreting quality metrics and participates in appropriate ICCE meetings, QAPIs, and/or other identified educational opportunities across the system.
Requirements
- Bachelor's degree in Nursing from an accredited school of nursing.
- Minimum of five years clinical nursing experience.
- Strong clinical experience and critical thinking skills.
- Extensive knowledge of patient care.
- 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.
- Current American Heart Association (AHA) Basic Life Support (BLS) certification or American Red Cross BLS for Healthcare Providers certification.
Nice To Haves
- Program and database development a plus.
Responsibilities
- Conduct reviews of inpatient electronic medical records to identify missing, vague, and/or incomplete diagnoses.
- Collaborate with and facilitate appropriate provider documentation to accurately reflect appropriate DRG (Diagnosis Related Group) assignment, patient severity of illness and risk of mortality.
- Risk adjust for expected mortality/length of stay.
- Clinically validate key diagnoses.
- Maintain a baseline understanding of interpreting quality metrics.
- Participate in appropriate ICCE meetings, QAPIs, and/or other identified educational opportunities across the system.
Benefits
- Participates in the federal E-Verify program to confirm the identity and employment authorization of all newly hired employees.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
