RN-Clinical Documentation Specialist I

Medical University of South Carolina; South Carolina; On-site; USD 65,000 - 85,000; Full time

Job summary

The RN – Clinical Documentation Specialist I at Medical University of South Carolina reviews inpatient electronic medical records to identify missing or vague diagnoses and facilitates physician documentation to accurately reflect severity of illness and risk of mortality.

You will collaborate with the medical staff, UR, coding, Quality, and the Center for Clinical Effectiveness to improve documentation quality.

Qualifications

• Bachelor's degree in nursing from an accredited school of nursing is required/preferred.
• Strong clinical experience and critical thinking skills are required.
• Licensure as a registered nurse by the South Carolina Board of Nursing or compact state.
• Experience with clinical documentation and quality improvement processes is beneficial.

Responsibilities

• Analyze and audit inpatient medical records concurrently to ensure specific, accurate, and complete clinical information.
• Educate physicians and clinicians to facilitate documentation reflecting severity of illness and risk of mortality.
• Collaborate with medical staff, UR, coding, Quality and Center for Clinical Effectiveness to improve documentation quality.
• Identify missing or vague diagnoses and facilitate appropriate physician documentation.

Education

Bachelor's degree in nursing

Job description

Job Description Summary

Job Description Summary The RN – Clinical Documentation Specialist I reports to the Manager, Clinical Documentation. Under general supervision, the RN – Clinical Documentation Specialist I conducts reviews of inpatient electronic medical records to identify missing, vague, and/or incomplete diagnoses and facilitates appropriate physician documentation to accurately reflect patient severity of illness and risk of mortality. In collaboration with the medical staff, faculty and nurse practitioners, UR, coding, Quality and the Center for Clinical Effectiveness, this role is charged with improving the quality of documentation for physicians and all caregivers. Entity Medical University Hospital Authority (MUHA) Worker Type Employee Worker Sub-Type Regular Cost Center CC002372 SYS - System Quality and Safety Pay Rate Type Salary Pay Grade Health-28 Scheduled Weekly Hours 40 Work Shift

Job Description

Job Description The Clinical Documentation Specialist is responsible for analyzing and auditing medical records concurrently to ensure that the clinical information within the medical record is specific, accurate, clinical valid, complete, and compliant. In addition, the Clinical Documentation Specialist is responsible for educating physicians, non-physician clinicians, nurses, and other staff to facilitate documentation within the medical record that reflects the most accurate severity of illness, expected risk of mortality, hospital acquired conditions, patient safety indicators, hierarchical condition categories, and level of service rendered. Additional Job Description Bachelor's degree in nursing from an accredited school of nursing and at least five years' clinical nursing experience preferred. Strong clinical experience and critical thinking skills required. Extensive knowledge of patient care, and knowledge of clinical measurement tools and clinical outcomes; ability to establish cooperative working relationships with diverse groups and individuals, medical staff and other health care disciplines. Licensure as a registered nurse by the South Carolina Board of Nursing or compact state. If you like working with energetic enthusiastic individuals, you will enjoy your career with us!

Equal Opportunity Employer Statement

The Medical University of South Carolina is an Equal Opportunity Employer.

MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations.

All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need.

Medical University of South Carolina participates in the federal E-Verify program to confirm the identity and employment authorization of all newly hired employees.

For further information about the E-Verify program, please click here: http://www.uscis.gov/e-verify/employees

About the Organization

Thank you for wanting to be part of the Medical University of South Carolina team. Whether you want to teach the next generation of health care leaders, innovate new business models, discover the next breakthrough or provide patient care, there's a role for you that fuels your passion and takes advantage of your skills. There are career opportunities available in academics, research, hospital medicine, physician practices and support services, from patient billing to IT. As an applicant, you can search jobs for all MUSC entities as well as search by category and location. MUSC attracts more than $250 million annually in research funding, making it the biggest magnet for biomedical, extramural research dollars of all institutions of higher learning in South Carolina. The Clinical and Translational Science Award (CTSA) Program aims to advance clinical and translational science to increase the speed at which new treatments become available to patients. MUSC Health, the clinical enterprise, operates a 750 bed medical center, which includes a nationally recognized Children’s Hospital, the Ashley River Tower (cardiovascular, digestive disease, and surgical oncology), Hollings Cancer Center (one of fewer than 70 elite National Cancer Institute designated centers), a Level I Trauma Center and the Institute of Psychiatry. In addition, there are more than 100 outreach clinics, hospital/health system affiliations, and telehealth sites. U.S. News & World Report placed us among the top one percent of all American hospitals, with 11 specialties in the top 50. The MUSC Medical Center is also one of only three Magnet® designated hospitals in South Carolina.