Medical University of South Carolina·South Carolina
The Clinical Documentation Specialist audits medical records to ensure clinical information is accurate, complete, and compliant with documentation standards. They also educate medical staff to facilitate documentation that accurately reflects patient severity of illness and risk of mortality.
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
The Clinical Documentation Specialist is responsible for analyzing and auditing medical records concurrently to ensure that the clinical information within the medical record is specific, accurate, clinical valid, complete, and compliant. In addition, the Clinical Documentation Specialist is responsible for educating physicians, non-physician clinicians, nurses, and other staff to facilitate documentation within the medical record that reflects the most accurate severity of illness, expected risk of mortality, hospital acquired conditions, patient safety indicators, hierarchical condition categories, and level of service rendered. Additional
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. 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
Candidates must hold a Bachelor's degree in nursing and possess at least five years of clinical nursing experience. A valid registered nurse license from the South Carolina Board of Nursing or a compact state is required.
Market context
Nursing jobs in South Carolina are typically in steady demand across hospitals, clinics, and long-term care settings. These roles are competitive because employers often want an active nursing license, BLS from the American Heart Association at hire, and may prefer a BSN; benefits commonly include medical, dental, vision, life insurance, and paid time off. Before applying, confirm your license status and BLS readiness, and note that the requirements and benefits on this platform are AI-summarized from the original job description to save research time.
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