Inpatient CDI Nurse Specialist I: Elevate DRG Accuracy

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

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.