RN Clinical Documentation Specialist I — Elevate Diagnoses & Care

experiencedAlliedHealth; South Carolina; On-site; USD 75,000 - 105,000; Full time

Job summary

MUHA is seeking an RN – Clinical Documentation Specialist I to review inpatient electronic medical records, identify missing or vague diagnoses, and collaborate with providers to accurately reflect DRG assignments, patient severity of illness and risk of mortality.

This role requires a Bachelor of Science in Nursing, SC RN licensure, and 5+ years of clinical nursing experience. It supports system-wide QA and education and is core to clinical documentation integrity.

Qualifications

• Bachelor's degree in nursing from an accredited school of nursing and at least five years' 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.

Responsibilities

• Review inpatient electronic medical records to identify missing or vague diagnoses.
• Collaborate with providers to facilitate documentation for accurate DRG assignment and severity.
• Interpret quality metrics and participate in ICCE meetings, QAPIs, and educational opportunities.

Skills

Clinical nursing

Critical thinking

Interdisciplinary collaboration

Education

Bachelor's degree in nursing

Job description

MUHA is seeking an RN – Clinical Documentation Specialist I to review inpatient electronic medical records, identify missing or vague diagnoses, and collaborate with providers to accurately reflect DRG assignments, patient severity of illness and risk of mortality.

This role requires a Bachelor of Science in Nursing, SC RN licensure, and 5+ years of clinical nursing experience. It supports system-wide QA and education and is core to clinical documentation integrity.