RN-Clinical Documentation Specialist I

Medical University of South Carolina • Florence, AL

3d

About The Position

The RN – Clinical Documentation Specialist I reports to the Manager, Clinical Documentation and works under general supervision. The role reviews inpatient electronic medical records to identify missing, vague, or incomplete diagnoses and facilitates appropriate physician documentation so the record accurately reflects patient severity of illness and risk of mortality. Working collaboratively with medical staff, faculty, nurse practitioners, utilization review, coding, Quality, and the Center for Clinical Effectiveness, the specialist helps improve documentation quality for physicians and other caregivers.

The Clinical Documentation Specialist analyzes and audits medical records concurrently to ensure clinical information is specific, accurate, clinically valid, complete, and compliant. The specialist also educates physicians, non-physician clinicians, nurses, and other staff to support documentation that reflects severity of illness, expected risk of mortality, hospital-acquired conditions, patient safety indicators, hierarchical condition categories, and the level of service rendered.

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 healthcare 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, and incomplete diagnoses.
• Facilitate appropriate physician documentation to accurately reflect patient severity of illness and risk of mortality.
• Analyze and audit medical records concurrently for specific, accurate, clinically valid, complete, and compliant clinical information.
• Educate physicians, non-physician clinicians, nurses, and other staff about documentation practices.
• Collaborate with medical staff, faculty, nurse practitioners, utilization review, coding, Quality, and the Center for Clinical Effectiveness to improve documentation quality.
• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: No Education Listed