RN CDI Specialist I — Elevate Inpatient Documentation

MUSC Health; Mullins (SC); On-site; USD 70,000 - 90,000; Full time

Job summary

The RN – Clinical Documentation Specialist I at MUSC Health reports to the Manager, Clinical Documentation. This role reviews inpatient electronic medical records to identify missing or vague diagnoses and supports physicians to ensure accurate severity of illness and risk of mortality documentation.

Candidates should have a Bachelor's degree in nursing and at least five years of clinical nursing experience, RN licensure in SC, and the ability to educate clinicians to improve documentation

Qualifications

• Bachelor's degree in nursing and at least five years of clinical nursing experience preferred.
• Licensure as a registered nurse by the South Carolina Board of Nursing or compact state.
• Strong clinical experience and critical thinking skills; ability to educate clinicians to improve documentation.

Responsibilities

• Analyze and audit inpatient records to ensure accurate reflecting of severity of illness and risk of mortality.
• Educate physicians, nurses, and other staff to improve documentation quality in the medical record.
• Collaborate with medical staff and departments to improve documentation standards and accuracy.

Skills

Clinical nursing experience

Critical thinking

Education

Bachelor's degree in nursing

Job description

The RN – Clinical Documentation Specialist I at MUSC Health reports to the Manager, Clinical Documentation. This role reviews inpatient electronic medical records to identify missing or vague diagnoses and supports physicians to ensure accurate severity of illness and risk of mortality documentation.

Candidates should have a Bachelor's degree in nursing and at least five years of clinical nursing experience, RN licensure in SC, and the ability to educate clinicians to improve documentation