RN Clinical Documentation Specialist I Elevate Patient Care

MUSC Health; Mullins (SC); On-site; USD 75,000 - 110,000; Full time

Job summary

The RN – Clinical Documentation Specialist I at MUSC Health reports to the Manager, Clinical Documentation and conducts reviews of inpatient electronic medical records to ensure diagnoses accurately reflect patient severity and risk. You will work with medical staff and other teams to improve documentation quality and support patient safety indicators.

This role requires a BSN, RN licensure in SC, and extensive clinical nursing experience with strong critical thinking skills.

Qualifications

• Bachelor's degree in 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 and improve physician documentation.
• Educate physicians, nurses and staff to reflect accurate severity of illness, risk of mortality and level of service.
• Collaborate with medical staff, UR, coding, HIS and quality teams to enhance documentation quality.

Skills

Nursing

Clinical documentation

Educating others

Collaboration

Education

BSN

RN license (SC)

Job description

The RN – Clinical Documentation Specialist I at MUSC Health reports to the Manager, Clinical Documentation and conducts reviews of inpatient electronic medical records to ensure diagnoses accurately reflect patient severity and risk. You will work with medical staff and other teams to improve documentation quality and support patient safety indicators.

This role requires a BSN, RN licensure in SC, and extensive clinical nursing experience with strong critical thinking skills.