RN-Clinical Documentation Specialist I (Columbia/Florence)
MUSC Health
Summary
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.
Job description
Job Description Summary
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.
Job Description
The RN (Registered Nurse) – Clinical Documentation Specialist I reports to their respective 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 collaborates with and facilitates 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.
Requirements
- 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
- 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
Company overview
MUSC Health is the healthcare system of the Medical University of South Carolina, serving as the state's premier academic medical center and comprehensive healthcare provider. Founded in 1824 and headquartered in Charleston, South Carolina, MUSC Health operates 14 hospitals with approximately 2,500 beds and has five additional hospital locations in development. The organization provides patient care through more than 350 telehealth sites and nearly 750 care locations across all regions of South Carolina, serving 46 counties throughout the state. For 11 consecutive years, U.S. News & World Report has ranked MUSC Health as the number one hospital in South Carolina, reflecting its commitment to clinical excellence and patient safety. As an integrated academic health system, MUSC Health combines clinical care with medical education and research, training more than 900 residents and fellows annually while conducting groundbreaking research with $360 million in research funding and 1,268 active clinical trials. The organization employs over 10,000 team members and handles approximately 3.21 million patient encounters each year, delivering specialized services in cancer care, cardiac services, digestive health, women's health, and numerous other medical specialties through its Hollings Cancer Center and other specialized institutes.