Clinical Documentation Specialist I

Job Description Summary 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. Entity Medical University Hospital Authority (MUHA) Worker Type Employee Worker Sub-Type​ Regular Cost Center CC005073 CHS - Clinical Documentation Pay Rate Type Salary Pay Grade Health-28 Scheduled Weekly Hours 40 Work Shift Job 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 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. Additional Job Description Bachelor's degree in nursing from an accredited school of nursing required 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. Physical Requirements  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: http://www.uscis.gov/e-verify/employees