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 Thank you for wanting to be part of the Medical University of South Carolina team. Whether you want to teach the next generation of health care leaders, innovate new business models, discover the next breakthrough or provide patient care, there's a role for you that fuels your passion and takes advantage of your skills. There are career opportunities available in academics, research, hospital medicine, physician practices and support services, from patient billing to IT. As an applicant, you can search jobs for all MUSC entities as well as search by category and location. MUSC attracts more than $250 million annually in research funding, making it the biggest magnet for biomedical, extramural research dollars of all institutions of higher learning in South Carolina. The Clinical and Translational Science Award (CTSA) Program aims to advance clinical and translational science to increase the speed at which new treatments become available to patients. MUSC Health, the clinical enterprise, operates a 750 bed medical center, which includes a nationally recognized Children’s Hospital, the Ashley River Tower (cardiovascular, digestive disease, and surgical oncology), Hollings Cancer Center (one of fewer than 70 elite National Cancer Institute designated centers), a Level I Trauma Center and the Institute of Psychiatry. In addition, there are more than 100 outreach clinics, hospital/health system affiliations, and telehealth sites. U.S. News & World Report placed us among the top one percent of all American hospitals, with 11 specialties in the top 50. The MUSC Medical Center is also one of only three Magnet® designated hospitals in South Carolina.