[Hiring] Clinical Documentation Specialist I @Medical University of South Carolina

Role Description

The RN (Registered Nurse) – Clinical Documentation Specialist I report to their respective Manager, Clinical Documentation. Under general supervision, the RN – Clinical Documentation Specialist I conduct reviews of inpatient electronic medical records to identify missing, vague, and/or incomplete diagnoses and collaborate with and facilitate appropriate provider documentation to accurately reflect appropriate DRG (Diagnosis Related Group) assignment, patient severity of illness and risk of mortality. In addition, the CDI (Clinical Documentation Integrity) specialist risk adjusts for expected mortality/length of stay and clinically validates key diagnoses. The RN – Clinical Documentation Specialist I is responsible for a baseline understanding of interpreting quality metrics and participates in appropriate ICCE meetings, QAPIs, and/or other identified educational opportunities across the system.

Qualifications

• Bachelor's degree in nursing from an accredited school of nursing
• At least 5+ years of experience as a Registered Nurse
• At least 3 years of experience working in a Pediatric Inpatient or Emergency Department setting preferred
• Licensure as a registered nurse by the South Carolina Board of Nursing or compact state
• Strong clinical experience and critical thinking skills required
• Extensive knowledge of patient care and clinical measurement tools
• Ability to establish cooperative working relationships with diverse groups and individuals, medical staff, and other health care disciplines

Requirements

• Position may require extensive walking
• May require frequent bending, stooping, or stretching
• May require lifting and carrying up to 20 lbs
• Requires eye-hand coordination and manual dexterity
• Requires the use of office equipment, such as computer terminals, telephones, and copiers
• Requires normal vision range and the absence of color blindness
• Ability to perform job functions while standing, sitting, and walking
• Ability to climb stairs
• Ability to work indoors and outdoors in temperature extremes
• Ability to work from elevated areas and in confined/cramped spaces
• Ability to perform job functions from kneeling positions
• Ability to bend at the waist, twist at the waist, and squat
• Ability to perform “pinching” operations and gross motor activities with fingers and hands
• Ability to perform firm grasping and fine manipulation with fingers and hands
• Ability to reach overhead and perform repetitive motions with hands/wrists/elbows and shoulders
• Ability to fully use both legs and lower extremities for balance and coordination
• Ability to lift and carry 50 lbs. unassisted
• Ability to lift/lower objects 50 lbs. from/to floor from/to 36 inches unassisted
• Ability to lift from 36” to overhead 25 lbs.
• Ability to exert up to 50 lbs. of force
• Ability to see and recognize objects close at hand or at a distance
• Ability to match or discriminate between colors
• Ability to determine distance/relationship between objects; depth perception
• Good peripheral vision capabilities
• Ability to maintain hearing acuity, with correction
• Ability to perform gross motor functions with frequent fine motor movements
• Ability to deal effectively with stressful situations
• Ability to work rotating shifts and overtime as required
• Ability to work in a latex safe environment
• Ability to maintain tactile sensory functions

Benefits

• If you like working with energetic enthusiastic individuals, you will enjoy your career with us!

Company Description

The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need.

Medical University of South Carolina participates in the federal E-Verify program to confirm the identity and employment authorization of all newly hired employees.