Clinical Documentation Specialist I-RN

MUSC Health; Mullins (SC); On-site; USD 75,000 - 110,000; Full time

Job summary

The RN – Clinical Documentation Specialist I at MUSC Health reports to the Manager, Clinical Documentation and conducts reviews of inpatient electronic medical records to ensure diagnoses accurately reflect patient severity and risk. You will work with medical staff and other teams to improve documentation quality and support patient safety indicators.

This role requires a BSN, RN licensure in SC, and extensive clinical nursing experience with strong critical thinking skills.

Qualifications

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

Responsibilities

• Review inpatient electronic medical records to identify missing or vague diagnoses and improve physician documentation.
• Educate physicians, nurses and staff to reflect accurate severity of illness, risk of mortality and level of service.
• Collaborate with medical staff, UR, coding, HIS and quality teams to enhance documentation quality.

Skills

Nursing

Clinical documentation

Educating others

Collaboration

Education

BSN

RN license (SC)

Job description

Job Description Summary

The RN – Clinical Documentation Specialist I reports to the Manager, Clinical Documentation. Under general supervision, the RN – Clinical Documentation Specialist I conducts reviews of inpatient electronic medical records to identify missing, vague, and/or incomplete diagnoses and facilitates appropriate physician documentation to accurately reflect patient severity of illness and risk of mortality. In collaboration with the medical staff, faculty and residents, HPA, UR, coding, HIS, Quality and the Center for Clinical Effectiveness, this role is charged with improving the quality of documentation for physicians and all caregivers.

Entity

Medical University Hospital Authority (MUHA)

Worker Type

Employee

Worker Sub-Type

Regular

Cost Center

CC005566 MAR - CDI

Pay Rate Type

Salary

Pay Grade

Health-28

Scheduled Weekly Hours

40

Work Shift

Job Description

The Clinical Documentation Specialist is responsible for analyzing and auditing medical records concurrently to ensure that the clinical information within the medical record is specific, accurate, clinical valid, complete, and compliant. In addition, the Clinical Documentation Specialist is responsible for educating physicians, non-physician clinicians, nurses, and other staff to facilitate documentation within the medical record that reflects the most accurate severity of illness, expected risk of mortality, hospital acquired conditions, patient safety indicators, hierarchical condition categories, and level of service rendered.

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.

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