Clinical Documentation Specialist I- Pediatrics

Medical University of South Carolina • Remote- South Carolina, SC

3d

About The Position

The RN – Clinical Documentation Specialist I reports to the Manager, Clinical Documentation and, under general supervision, reviews inpatient electronic medical records to identify missing, vague, or incomplete diagnoses. The specialist collaborates with providers and facilitates appropriate documentation so records accurately reflect diagnoses, DRG assignment, patient severity of illness, and risk of mortality. The role also risk-adjusts expected mortality and length of stay and clinically validates key diagnoses. The specialist maintains a baseline understanding of quality metrics and participates in appropriate ICCE meetings, QAPIs, and other identified educational opportunities across the system.

Requirements

• Bachelor's degree in nursing from an accredited school of nursing.
• At least 5 years of experience as a Registered Nurse.
• Licensure as a registered nurse by the South Carolina Board of Nursing or a compact state.
• Strong clinical experience and critical thinking skills.
• 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.

Nice To Haves

• At least 3 years of experience working in a Pediatric Inpatient or Emergency Department setting is preferred.
• CDI experience is highly preferred.

Responsibilities

• Review inpatient electronic medical records to identify missing, vague, or incomplete diagnoses.
• Collaborate with providers and facilitate appropriate documentation.
• Support accurate DRG assignment and documentation of patient severity of illness and risk of mortality.
• Risk-adjust for expected mortality and length of stay.
• Clinically validate key diagnoses.
• Interpret quality metrics at a baseline level.
• Participate in appropriate ICCE meetings, QAPIs, and other identified educational opportunities across the system.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level