RN Clinical Documentation Specialist I - Drive DRG Accuracy

C002 Medical University Hospital Authority (MUHA); South Carolina; Hybrid; USD 65,000 - 85,000; Full time

Job summary

The Medical University of South Carolina is seeking an experienced RN – Clinical Documentation Specialist I to review inpatient electronic medical records, collaborate with providers, and ensure accurate DRG assignments reflecting patient severity and mortality risk.

Responsibilities include interpreting quality metrics, participating in ICCE meetings and QAPIs, and promoting quality documentation across the system.

Qualifications

• Bachelor's degree in nursing from an accredited school.
• At least five years of clinical nursing experience preferred.
• 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, and/or incomplete diagnoses.
• Collaborate with and facilitate provider documentation to accurately reflect DRG assignment, patient severity of illness and risk of mortality.
• Interpret quality metrics and participate in ICCE meetings, QAPIs, and other educational opportunities across the system.
• Maintain cooperative working relationships with medical staff and other health care disciplines.

Skills

Clinical experience

Critical thinking

Education

Bachelor's degree in nursing

Job description

The Medical University of South Carolina is seeking an experienced RN – Clinical Documentation Specialist I to review inpatient electronic medical records, collaborate with providers, and ensure accurate DRG assignments reflecting patient severity and mortality risk.

Responsibilities include interpreting quality metrics, participating in ICCE meetings and QAPIs, and promoting quality documentation across the system.