Clinical Documentation Specialist I-RN

Medical University of South Carolina

20h • Onsite

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

• Licensure as a registered nurse by the South Carolina Board of Nursing or compact state.
• 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.
• Requires eye-hand coordination and manual dexterity.
• Requires the use of office equipment, such as computer terminals, telephones, and copiers.
• Requires normal vision range and the absence of color blindness.
• Ability to perform job functions while standing.
• Ability to perform job functions while sitting.
• Ability to perform job functions while walking.
• Ability to work indoors.
• Ability to perform “pinching” operations.
• Ability to perform gross motor activities with fingers and hands.
• Ability to perform firm grasping with fingers and hands.
• Ability to perform fine manipulation with fingers and hands.
• Ability to perform repetitive motions with hands/wrists/elbows and shoulders.
• Ability to fully use both legs.
• Ability to reach in all directions.
• Ability to see and recognize objects close at hand or at a distance.
• Ability to match or discriminate between colors.
• Ability to determine distance/relationship between objects; depth perception.
• Good peripheral vision capabilities.
• Ability to maintain hearing acuity, with correction.
• Ability to perform gross motor functions with frequent fine motor movements.
• Ability to deal effectively with stressful situations.
• Ability to work in a latex safe environment.

Nice To Haves

• Bachelor's degree in nursing from an accredited school of nursing.
• At least five years' clinical nursing experience preferred.
• Ability to climb stairs.
• Ability to work outside in temperature extremes.
• Ability to work from elevated areas.
• Ability to work in confined/cramped spaces.
• Ability to perform job functions from kneeling positions.
• Ability to bend at the waist.
• Ability to twist at the waist.
• Ability to squat and perform job functions.
• Ability to reach overhead.
• Ability to use lower extremities for balance and coordination.
• Ability to lift and carry 50 lbs. unassisted.
• Ability to lift/lower objects 50 lbs. from/to floor from/to 36 inches unassisted.
• Ability to lift from 36” to overhead 25 lbs.
• Ability to exert up to 50 lbs. of force.
• Ability to work rotating shifts.
• Ability to work overtime as required.

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 and 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 501-1,000 employees