Clinical Documentation Specialist I

Overview Job Description Summary The RN (Registered Nurse) – 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 collaborates with and facilitates appropriate provider documentation to accurately reflect DRG assignment, patient severity of illness, and risk of mortality. The CDI (Clinical Documentation Integrity) specialist also risk adjusts for expected mortality/length of stay and clinically validates key diagnoses. The RN – Clinical Documentation Specialist I participates in interpreting quality metrics and attends ICCE meetings, QAPIs, and other identified educational opportunities across the system. Entity Medical University Hospital Authority (MUHA) Worker Type Employee Worker Sub-Type Regular Cost Center CC004847 ORBG - Quality Assurance Pay Rate Type Salary Pay Grade Health-28 Scheduled Weekly Hours 40 Work Shift Job Description The RN (Registered Nurse) – 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 collaborates with and facilitates appropriate provider documentation to accurately reflect DRG assignment, patient severity of illness and risk of mortality. 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. 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. Mobility & Posture Standing: Continuous Sitting: Continuous Walking: Continuous Climbing stairs: Infrequent Working indoors: Continuous Working outdoors (temperature extremes): Infrequent Working from elevated areas: Frequent Working in confined/cramped spaces: Frequent Kneeling: Infrequent Bending at the waist: Continuous Twisting at the waist: Frequent Squatting: Frequent Manual Dexterity & Strength Pinching operations: Frequent Gross motor use (fingers/hands): Continuous Firm grasping (fingers/hands): Continuous Fine manipulation (fingers/hands): Continuous Reaching overhead: Frequent Reaching in all directions: Continuous Repetitive motion (hands/wrists/elbows/shoulders): Continuous Full use of both legs: Continuous Balance & coordination (lower extremities): Frequent Lifting & Force Requirements Lift/carry 50 lbs. unassisted: Infrequent Lift/lower 50 lbs. from floor to 36”: Infrequent Lift up to 25 lbs. overhead: Infrequent Exert up to 50 lbs. of force: Frequent Examples: Transfer 100 lb. non-ambulatory patient = 50 lbs. force Push 400 lb. patient in wheelchair on carpet = 20 lbs. force Push patient stretcher one-handed = 25 lbs. force Vision & Sensory Maintain corrected vision 20/40 (one or both eyes): Continuous Recognize objects (near/far): Continuous Color discrimination: Continuous Depth perception: Continuous Peripheral vision: Continuous Hearing acuity (with correction): Continuous Tactile sensory function: Continuous Gross motor with fine motor coordination: Continuous Selected Positions: Olfactory (smell) function: Continuous Respirator use qualification: Continuous Work Environment & Conditions Effective stress management: Continuous Rotating shifts: Frequent Overtime as required: Frequent Latex-safe environment: Continuous 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. Medical University of South Carolina participates in the federal E-Verify program to confirm the identity and employment authorization of all newly hired employees. For further information about the E-Verify program, please click here: #J-18808-Ljbffr