Clinical Documentation Specialist I- Pediatrics

Medical University of South Carolina; South Carolina; Hybrid; USD 70,000 - 90,000; Full time

Job summary

The RN (Registered Nurse) – Clinical Documentation Specialist I at Medical University Hospital Authority conducts reviews of inpatient electronic medical records to identify missing or vague diagnoses and to facilitate provider documentation for accurate DRG assignment and patient severity.

Under supervision, CDI initiatives are supported and quality metrics are interpreted to improve patient care system-wide.

Qualifications

• Bachelor's degree in nursing and 5+ years of RN experience, including pediatric inpatient or ED experience preferred.
• Licensure as a registered nurse by the SC Board of Nursing or a compact state.
• CDI experience highly preferred.
• Strong clinical experience and critical thinking skills.

Responsibilities

• Review inpatient electronic medical records to identify missing, vague, or incomplete diagnoses.
• Collaborate with providers to ensure accurate documentation reflecting DRG assignment and patient severity.
• Participate in quality metrics interpretation and CDI initiatives across the system.

Skills

Critical thinking

Education

Bachelor's degree in nursing

RN licensure (SC Board of Nursing or compact state)

Job description

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.

Entity

Medical University Hospital Authority (MUHA)

Worker Type

Employee

Worker Sub-Type

Regular

Cost Center

CC005073 CHS OH - Clinical Documentation

Pay Rate Type

Salary

Pay Grade

Health-28

Scheduled Weekly Hours

40

Minimum Qualifications

Bachelor's degree in nursing from an accredited school of nursing and at least 5+ years of experience as a Registered Nurse, including at least 3 years of experience working in a Pediatric Inpatient or Emergency Department setting experience preferred.

Licensure as a registered nurse by the South Carolina Board of Nursing or compact state.

CDI experience highly 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.

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.

Additional 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.

Physical Requirements

• *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