RN CDI Specialist I - Elevate Documentation Quality

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

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