RN-Clinical Documentation Specialist I (Columbia/Florence)

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. Medical University Hospital Authority (MUHA) Worker Type CC002372 SYS - System Quality and Safety Pay Rate Type Health-28 Scheduled Weekly Hours 40 Work Shift Bachelor's degree in nursing from an accredited school of nursing and at least five years' clinical nursing experience preferred. 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. 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. 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. Requires the use of office equipment, such as computer terminals, telephones, and copiers. *C) Continuous – 6-8 hours per shift; 2) (F) Frequent – 2-6 hours per shift; 3) (I) Infrequent – 0-2 hours per shift I) Ability to perform “pinching” operations. (from/to floor from/to 36 inches unassisted. (C) Ability to work rotating shifts. (I) Ability to work overtime as required. (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. Medical University of South Carolina participates in the federal E-Verify program to confirm the identity and employment authorization of all newly hired employees.