RN CDI Specialist I – Elevate Medical Records

Medical University of South Carolina; Mullins (SC); On-site; USD 75,000 - 105,000; Full time

Job summary

Medical University of South Carolina seeks an RN – Clinical Documentation Specialist I to review inpatient records, improve documentation accuracy, and educate clinicians on documenting severity and outcomes.

The role emphasizes collaboration with diverse health care teams to ensure precise coding and compliant documentation. A SC RN license and substantial nursing experience are preferred.

Qualifications

• Bachelor's degree in nursing is required.
• RN license by SC Board of Nursing or a compact state is required or preferred.
• Strong clinical experience and critical thinking skills are required.
• Extensive knowledge of patient care and clinical measurement tools/outcomes is needed.
• Ability to establish cooperative relationships with diverse groups and health care professionals.

Responsibilities

• Audit inpatient records concurrently to ensure accuracy and completeness.
• Educate physicians and staff to improve documentation quality.
• Collaborate with medical staff to reflect severity of illness, risk of mortality, and care level.
• Support compliance with hospital documentation standards and regulations.

Skills

Clinical nursing experience

Critical thinking

Patient care knowledge

Interdisciplinary collaboration

Documentation knowledge

Education

Bachelor's degree in nursing

RN license (SC or compact)

Job description

Medical University of South Carolina seeks an RN – Clinical Documentation Specialist I to review inpatient records, improve documentation accuracy, and educate clinicians on documenting severity and outcomes.

The role emphasizes collaboration with diverse health care teams to ensure precise coding and compliant documentation. A SC RN license and substantial nursing experience are preferred.