[Hiring] Clinical Documentation Specialist I - RN-1 @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.
• Collaborate with and facilitate appropriate provider documentation to accurately reflect:
• Appropriate DRG (Diagnosis Related Group) assignment
• Patient severity of illness
• Risk of mortality
• Risk adjust for expected mortality/length of stay and clinically validate key diagnoses.
• Maintain a baseline understanding of interpreting quality metrics.
• Participate 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 five years' clinical nursing experience preferred.
• 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.
• Licensure as a registered nurse by the South Carolina Board of Nursing or compact state.
• Current American Heart Association (AHA) Basic Life Support (BLS) certification or American Red Cross BLS for Healthcare Providers certification is required.

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 in confined/cramped spaces.
• Ability to perform job functions from kneeling positions.
• Ability to bend, twist, squat, and perform "pinching" operations.
• Ability to perform gross motor activities with fingers and hands.
• Ability to lift and carry 50 lbs. unassisted.
• Ability to maintain hearing acuity, with correction.
• Ability to deal effectively with stressful situations.
• Ability to work rotating shifts and overtime as required.
• Ability to work in a latex safe environment.

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.