RN-Clinical Documentation Specialist I

Job Description Summary

The RN – Clinical Documentation Specialist I reports to the Manager, Clinical Documentation. Under general supervision, the RN – Clinical Documentation Specialist I conducts reviews of inpatient electronic medical records to identify missing, vague, and/or incomplete diagnoses and facilitates appropriate physician documentation to accurately reflect patient severity of illness and risk of mortality. In collaboration with the medical staff, faculty and nurse practitioners, UR, coding, Quality and the Center for Clinical Effectiveness, this role is charged with improving the quality of documentation for physicians and all caregivers.

Entity

Medical University Hospital Authority (MUHA)

Worker Type

Employee

Worker Sub-Type​

Regular

Cost Center

CC002372 SYS - System Quality and Safety

Pay Rate Type

Salary

Pay Grade

Health-28

Scheduled Weekly Hours

40

Work Shift

Job Description

The Clinical Documentation Specialist is responsible for analyzing and auditing medical records concurrently to ensure that the clinical information within the medical record is specific, accurate, clinical valid, complete, and compliant. In addition, the Clinical Documentation Specialist is responsible for educating physicians, non-physician clinicians, nurses, and other staff to facilitate documentation within the medical record that reflects the most accurate severity of illness, expected risk of mortality, hospital acquired conditions, patient safety indicators, hierarchical condition categories, and level of service rendered.

Additional Job Description

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 knowledge of clinical measurement tools and clinical outcomes; 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.  

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

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.

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