RN Clinical Documentation Specialist I — Elevate DRG Accuracy

MUSC Health; South Carolina; On-site; USD 75,000 - 95,000; Full time

Job summary

The Medical University of South Carolina seeks an RN - Clinical Documentation Specialist I to review inpatient records for missing or vague diagnoses and to facilitate provider documentation ensuring accurate DRG assignment and patient severity of illness. You will support CDI initiatives and participate in system-wide quality education.

Bachelor's in nursing and at least five years of clinical nursing experience are preferred; SC RN licensure or compact state is required.

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 measurement tools/outcomes.
• Licensure as a registered nurse by SC Board of Nursing or compact state.

Responsibilities

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

Skills

Nursing

Critical thinking

Documentation

Team collaboration

Education

Bachelor's degree in nursing

Job description

The Medical University of South Carolina seeks an RN - Clinical Documentation Specialist I to review inpatient records for missing or vague diagnoses and to facilitate provider documentation ensuring accurate DRG assignment and patient severity of illness. You will support CDI initiatives and participate in system-wide quality education.

Bachelor's in nursing and at least five years of clinical nursing experience are preferred; SC RN licensure or compact state is required.