RN CDI Specialist I - Drive DRG Accuracy & Documentation

Medical University of South Carolina; United States; Remote; USD 80,000 - 110,000; Full time

Job summary

The RN - Clinical Documentation Specialist I at Medical University of South Carolina reports to the Manager, Clinical Documentation. Under general supervision, you will review inpatient EMRs to identify missing or unclear diagnoses and collaborate with providers to ensure accurate DRG assignment and patient severity of illness.

You will also support CDI activities and quality metrics across the system. You will participate in ICCE meetings, QAPIs, and other educational opportunities,

Qualifications

• Bachelor's degree in nursing from an accredited school, with at least five years' clinical nursing experience.
• Strong clinical experience and critical thinking skills.
• Knowledge of patient care and clinical measurement tools; ability to work with diverse teams and healthcare professionals.
• Licensed as RN by SC Board of Nursing or compact state.

Responsibilities

• Review inpatient electronic medical records to identify missing, vague, or incomplete diagnoses and collaborate with providers to reflect accurate DRG assignment.
• Risk adjust for expected mortality/length of stay and clinically validate key diagnoses.
• Interpret quality metrics and participate in ICCE meetings, QAPIs, and other identified educational opportunities across the system.

Skills

Critical thinking

Nursing licensure

Team collaboration

Patient care knowledge

Education

Bachelor's degree in nursing

Job description

The RN - Clinical Documentation Specialist I at Medical University of South Carolina reports to the Manager, Clinical Documentation. Under general supervision, you will review inpatient EMRs to identify missing or unclear diagnoses and collaborate with providers to ensure accurate DRG assignment and patient severity of illness.

You will also support CDI activities and quality metrics across the system. You will participate in ICCE meetings, QAPIs, and other educational opportunities,