Clinical Documentation Specialist I-RN

Medical University of South Carolina; United States; On-site; USD 65,000 - 90,000; Full time

Job summary

The Clinical Documentation Specialist I at the Medical University of South Carolina works under supervision to review inpatient electronic medical records, identify missing or vague diagnoses, and facilitate physician documentation to accurately reflect illness severity and mortality risk.

The role emphasizes education of physicians, non-physician clinicians, nurses, and staff to improve documentation quality, ensure compliance, and support hospital coding and quality initiatives within MUSC's

Qualifications

• Bachelor’s degree in nursing required.
• Experience in clinical nursing and familiarity with documentation best practices preferred.
• Ability to educate physicians and staff to improve documentation quality and accuracy.

Responsibilities

• Analyze and audit inpatient medical records to ensure accurate diagnosis and reflect illness severity and mortality risk.
• Educate physicians, nurses, and other staff to facilitate compliant documentation within medical records.
• Collaborate with medical staff, coding, HIS, and quality teams to improve documentation quality.

Skills

Clinical nursing

Clinical documentation

Education to physicians and staff

Auditing medical records

Education

Bachelor's degree in nursing

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 & Compensation

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

Job Description

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

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.

Equal Opportunity Statement

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.

E-Verify Program

Medical University of South Carolina participates in the federal E-Verify program to confirm the identity and employment authorization of all newly hired employees.

We Invite You

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.