Clinical Documentation Specialist I-RN

Medical University of South Carolina • Columbia, SC

2d

About The Position

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 residents, HPA, UR, coding, HIS, Quality and the Center for Clinical Effectiveness, this role is charged with improving the quality of documentation for physicians and all caregivers. The Clinical Documentation Specialist is responsible for analyzing and auditing medical records concurrently to ensure that the clinical information within the medical record is specific, accurate, clinical valid, complete, and compliant. In addition, the Clinical Documentation Specialist is responsible for educating physicians, non-physician clinicians, nurses, and other staff to facilitate documentation within the medical record 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
• Minimum of (5) five years clinical nursing experience required.
• 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 relationship with diverse groups and individuals, medical staff and other health care disciplines
• Licensure 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 is required.

Nice To Haves

• program and database development a plus.

Responsibilities

• Conducts reviews of inpatient electronic medical records to identify missing, vague, and/or incomplete diagnoses
• Facilitates appropriate physician documentation to accurately reflect patient severity of illness and risk of mortality
• Analyzing and auditing medical records concurrently to ensure that the clinical information within the medical record is specific, accurate, clinical valid, complete, and compliant.
• Educating physicians, non-physician clinicians, nurses, and other staff to facilitate documentation within the medical record 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees