RN Clinical Documentation Specialist

Medical University of South Carolina • Orangeburg, SC

419d

About The Position

The Clinical Documentation Specialist is responsible for analyzing and auditing medical records to ensure accuracy, completeness, and compliance. This role involves educating healthcare staff to enhance documentation quality, reflecting the severity of illness and other critical clinical indicators.

Requirements

• Bachelor's degree in Nursing from an accredited school.
• Minimum of five years clinical nursing experience.
• Strong clinical experience and critical thinking skills.
• Extensive knowledge of patient care and clinical measurement tools.
• Registered nurse licensure by the South Carolina Board of Nursing or compact state.
• Current AHA Basic Life Support (BLS) certification.

Nice To Haves

• Knowledge of program and database development.

Responsibilities

• Analyze and audit medical records for accuracy and compliance.
• Educate physicians and healthcare staff on proper documentation practices.
• Ensure clinical information reflects severity of illness and patient safety indicators.
• Collaborate with diverse healthcare professionals to improve documentation quality.

What This Job Offers

• Job Type: Full-time
• Industry: Educational Services
• Education Level: Bachelor's degree