RN Clinical Documentation Specialist I: Elevate Patient Care

Medical University of South Carolina; South Carolina; On-site; USD 85,000 - 110,000; Full time

Job summary

Medical University of South Carolina is seeking an RN – Clinical Documentation Specialist I to review inpatient records, identify missing or vague diagnoses, and collaborate with providers to ensure accurate DRG assignment and patient severity. Under general supervision, you will participate in ICCE meetings and QAPIs, interpret quality metrics, and support system-wide clinical documentation.

A BSN and five years of nursing experience plus SC RN licensure are preferred; this is an on-site role

Qualifications

• Bachelor's degree in nursing from an accredited school of nursing; 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 required.

Responsibilities

• Review inpatient electronic medical records to identify missing, vague, and/or incomplete diagnoses.
• Collaborate with providers to ensure documentation reflects accurate DRG assignment and patient severity of illness.
• Interpret quality metrics and participate in ICCE meetings, QAPIs, and other educational opportunities across the system.

Education

Bachelor's degree in nursing

Job description

Medical University of South Carolina is seeking an RN – Clinical Documentation Specialist I to review inpatient records, identify missing or vague diagnoses, and collaborate with providers to ensure accurate DRG assignment and patient severity. Under general supervision, you will participate in ICCE meetings and QAPIs, interpret quality metrics, and support system-wide clinical documentation.

A BSN and five years of nursing experience plus SC RN licensure are preferred; this is an on-site role