Clinical Documentation Specialist I- Midlands

C002 Medical University Hospital Authority (MUHA); South Carolina; Ibrido; USD 65.000 - 85.000; Tempo pieno

Descrizione del lavoro

The Medical University of South Carolina is seeking an experienced RN – Clinical Documentation Specialist I to review inpatient electronic medical records, collaborate with providers, and ensure accurate DRG assignments reflecting patient severity and mortality risk.

Responsibilities include interpreting quality metrics, participating in ICCE meetings and QAPIs, and promoting quality documentation across the system.

Competenze

• Bachelor's degree in nursing from an accredited school.
• At least five years of clinical nursing experience preferred.
• Licensure as a registered nurse by the South Carolina Board of Nursing or a compact state.

Mansioni

• Review inpatient electronic medical records to identify missing, vague, and/or incomplete diagnoses.
• Collaborate with and facilitate provider documentation to accurately reflect DRG assignment, patient severity of illness and risk of mortality.
• Interpret quality metrics and participate in ICCE meetings, QAPIs, and other educational opportunities across the system.
• Maintain cooperative working relationships with medical staff and other health care disciplines.

Conoscenze

Clinical experience

Critical thinking

Formazione

Bachelor's degree in nursing

Descrizione del lavoro

Job Description Summary

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. Bachelor's degree in nursing from an accredited school of nursing and at least five years' clinical nursing experience preferred. Strong clinical experience and critical thinking skills required. 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. Licensure as a registered nurse by the South Carolina Board of Nursing or compact state.

Entity Medical University Hospital Authority (MUHA) Worker Type Employee Worker Sub-Type Regular Cost Center CC003762 COL - CDI Chart Documentation (DMC) Pay Rate Type Salary Pay Grade Health-28 Scheduled Weekly Hours 40 Work Shift

Job Description

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. Bachelor's degree in nursing from an accredited school of nursing and at least five years' clinical nursing experience preferred. Strong clinical experience and critical thinking skills required. 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. Licensure as a registered nurse by the South Carolina Board of Nursing or compact state.

• Position may require extensive walking.
• May require frequent bending, stooping, or stretching.
• May require lifting and carrying up to 20 lbs.
• Requires eye-hand coordination and manual dexterity.
• Requires the use of office equipment, such as computer terminals, telephones, and copiers.
• Requires normal vision range and the absence of color blindness.

(C) Continuous – 6-8 hours per shift; 2) (F) Frequent – 2-6 hours per shift; 3) (I) Infrequent – 0-2 hours per shift Ability to perform job functions while standing. (C). Ability to perform job functions while sitting. (C) Ability to perform job functions while walking. (C) Ability to climb stairs. (F) Ability to work indoors. (C) Ability to work outside in temperature extremes. (I) Ability to work from elevated areas. (I) Ability to work in confined/cramped spaces. (F) Ability to perform job functions from kneeling positions. (I) Ability to bend at the waist. (F) Ability to twist at the waist. (F) Ability to squat and perform job functions. (I) Ability to perform “pinching” operations. (C) Ability to perform gross motor activities with fingers and hands. (C) Ability to perform firm grasping with fingers and hands. (C) Ability to perform fine manipulation with fingers and hands. (C) Ability to reach overhead. (I) Ability to perform repetitive motions with hands/wrists/elbows and shoulders. (C) Ability to fully use both legs. (C) Ability to use lower extremities for balance and coordination. (F) Ability to reach in all directions. (C) Ability to lift and carry 50 lbs. unassisted. (I) Ability to lift/lower objects 50 lbs. from/to floor from/to 36 inches unassisted. (I) Ability to lift from 36” to overhead 25 lbs. (I) Ability to exert up to 50 lbs. of force. (I) Ability to see and recognize objects close at hand or at a distance. (C) Ability to match or discriminate between colors. (C) Ability to determine distance/relationship between objects; depth perception. (C) Good peripheral vision capabilities. (C) Ability to maintain hearing acuity, with correction. (C) Ability to perform gross motor functions with frequent fine motor movements. (C) Ability to deal effectively with stressful situations. (C) Ability to work rotating shifts. (I) Ability to work overtime as required. (I) Ability to work in a latex safe environment. (C) Ability to maintain tactile sensory functions. (C)

Additional Job Description

Bachelor's degree in nursing from an accredited school of nursing and at least five years' clinical nursing experience preferred. Strong clinical experience and critical thinking skills required. 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. Licensure as a registered nurse by the South Carolina Board of Nursing or compact state. If you like working with energetic enthusiastic individuals, you will enjoy your career with us! The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need. Medical University of South Carolina participates in the federal E-Verify program to confirm the identity and employment authorization of all newly hired employees.

Thank you for wanting to be part of the Medical University of South Carolina team. Whether you want to teach the next generation of health care leaders, innovate new business models, discover the next breakthrough or provide patient care, there's a role for you that fuels your passion and takes advantage of your skills.

There are career opportunities available in academics, research, hospital medicine, physician practices and support services, from patient billing to IT. As an applicant, you can search jobs for all MUSC entities as well as search by category and location. MUSC attracts more than $250 million annually in research funding, making it the biggest magnet for biomedical, extramural research dollars of all institutions of higher learning in South Carolina.

The Clinical and Translational Science Award (CTSA) Program aims to advance clinical and translational science to increase the speed at which new treatments become available to patients.

MUSC Health, the clinical enterprise, operates a 750 bed medical center, which includes a nationally recognized Children’s Hospital, the Ashley River Tower (cardiovascular, digestive disease, and surgical oncology), Hollings Cancer Center (one of fewer than 70 elite National Cancer Institute designated centers), a Level I Trauma Center and the Institute of Psychiatry.

In addition, there are more than 100 outreach clinics, hospital/health system affiliations, and telehealth sites.

U.S. News & World Report placed us among the top one percent of all American hospitals, with 11 specialties in the top 50.

The MUSC Medical Center is also one of only three Magnet® designated hospitals in South Carolina.