RN Clinical Documentation Specialist I — Drive Accurate DRG

Medical University of South Carolina; United States; Remote; USD 80,000 - 105,000; Full time

Job summary

The RN (Registered Nurse) – Clinical Documentation Specialist I at Medical University of South Carolina conducts reviews of inpatient electronic medical records to identify missing, vague, and/or incomplete diagnoses and collaborates with providers to accurately reflect DRG assignment, patient severity, and mortality risk.

The role supports quality metrics through ICCE meetings and educational activities across MUHA.

Qualifications

• 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 clinical outcomes; ability to establish cooperative working relationships with medical staff and other health care disciplines.
• Licensure as a registered nurse by the South Carolina Board of Nursing or a compact state.

Responsibilities

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

Skills

Clinical nursing experience

Critical thinking

Education

Bachelor's degree in nursing

Job description

The RN (Registered Nurse) – Clinical Documentation Specialist I at Medical University of South Carolina conducts reviews of inpatient electronic medical records to identify missing, vague, and/or incomplete diagnoses and collaborates with providers to accurately reflect DRG assignment, patient severity, and mortality risk.

The role supports quality metrics through ICCE meetings and educational activities across MUHA.