Clinical Documentation Specialist I-RN

Medical University of South Carolina • Mullins, SC

4d

About The Position

The RN – Clinical Documentation Specialist I reports to the Manager, Clinical Documentation and works under general supervision. The specialist reviews inpatient electronic medical records to identify missing, vague, or incomplete diagnoses and works with physicians to facilitate documentation that accurately reflects patients’ severity of illness and risk of mortality.

The position analyzes and audits medical records concurrently to ensure clinical information is specific, accurate, clinically valid, complete, and compliant. It also educates physicians, non-physician clinicians, nurses, and other staff to support accurate documentation of severity of illness, expected risk of mortality, hospital-acquired conditions, patient safety indicators, hierarchical condition categories, and level of service rendered. The specialist collaborates with medical staff, faculty and residents, HPA, UR, coding, HIS, Quality, and the Center for Clinical Effectiveness to improve documentation quality for physicians and other caregivers.

Requirements

• 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 a compact state.

Nice To Haves

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

Responsibilities

• Review inpatient electronic medical records to identify missing, vague, or incomplete diagnoses.
• Facilitate appropriate physician documentation so records accurately reflect patient severity of illness and risk of mortality.
• Analyze and audit medical records concurrently to ensure clinical information is specific, accurate, clinically valid, complete, and compliant.
• Educate physicians, non-physician clinicians, nurses, and other staff about documentation practices.
• Support documentation that reflects severity of illness, expected risk of mortality, hospital-acquired conditions, patient safety indicators, hierarchical condition categories, and level of service rendered.
• Collaborate with medical staff, faculty and residents, HPA, UR, coding, HIS, Quality, and the Center for Clinical Effectiveness to improve documentation quality.

What This Job Offers

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