Pediatric CDI RN — Clinical Documentation Specialist I

Medical University of South Carolina; United States; Remote; USD 70,000 - 90,000; Full time

Job summary

The RN – Clinical Documentation Specialist I at Medical University of South Carolina conducts reviews of inpatient electronic medical records to identify missing or vague diagnoses and collaborates with providers to ensure accurate DRG assignment reflecting patient severity and risk of mortality.

Under supervision, this role supports baseline interpretation of quality metrics and participates in ICCE meetings, QAPIs, and related educational opportunities across the system.

Qualifications

• Bachelor's degree in nursing required.
• 5+ years as a Registered Nurse, including at least 3 years in Pediatric Inpatient or ED.
• SC Board of Nursing licensure or compact state licensure required.
• CDI experience highly preferred.

Responsibilities

• Review inpatient electronic medical records to identify missing or vague diagnoses and collaborate with providers to accurately reflect DRG assignment.
• Facilitate appropriate provider documentation to reflect patient severity of illness and risk of mortality.
• Engage in quality metrics interpretation and participate in system-wide educational activities.

Skills

RN experience

Pediatrics

Clinical Documentation

Education

Bachelor's degree in nursing

Job description

The RN – Clinical Documentation Specialist I at Medical University of South Carolina conducts reviews of inpatient electronic medical records to identify missing or vague diagnoses and collaborates with providers to ensure accurate DRG assignment reflecting patient severity and risk of mortality.

Under supervision, this role supports baseline interpretation of quality metrics and participates in ICCE meetings, QAPIs, and related educational opportunities across the system.