Clinical Documentation Specialist I

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

2d • 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.
• 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

• Bachelor's degree in nursing from an accredited school of nursing.
• At least five years' clinical nursing experience.

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.

What This Job Offers

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