Clinical Documentation Specialist -RN

Clinical Documentation Specialist I – RN

Job Summary:

The RN – Clinical Documentation Specialist I reports to the Manager, Clinical Documentation and is responsible for reviewing inpatient electronic medical records, identifying missing or incomplete diagnoses and facilitating accurate physician documentation that reflects patient severity of illness and risk of mortality. In collaboration with the medical staff, faculty, residents, HPA, UR, coding, HIS, Quality and the Center for Clinical Effectiveness, this role is charged with improving documentation quality for all caregivers.

• Review inpatient electronic medical records to identify missing, vague, or incomplete diagnoses.
• Facilitate appropriate physician documentation to accurately reflect patient severity of illness and risk of mortality.
• Analyze and audit medical records to ensure specificity, accuracy, clinical validity, completeness, and compliance.
• Educate physicians, non‑physician clinicians, nurses, and other staff on documentation that reflects accurate severity of illness, expected risk of mortality, hospital acquired conditions, patient safety indicators, hierarchical condition categories, and level of service rendered.
• Collaborate with medical staff, faculty, residents, HPA, UR, coding, HIS, Quality, and the Center for Clinical Effectiveness to improve documentation quality.

• Bachelor’s degree in Nursing from an accredited school of nursing and a minimum of five years clinical nursing experience.
• Strong clinical experience with critical‑thinking skills, extensive knowledge of patient care, clinical measurement tools, and clinical outcomes.
• Ability to establish a cooperative working relationship with diverse groups and individuals, medical staff and other health‑care disciplines.
• Program and database development experience a plus.
• Registered Nurse licensure by the South Carolina Board of Nursing or compact state.
• Current AHA Basic Life Support (BLS) certification or American Red Cross BLS for Healthcare Providers certification.
• Physical requirements:
  
  standing and walking for 6–8 hours per shift; climbing stairs; working indoors and from elevated areas; working in confined spaces; performing repetitive motions; lifting up to 15 lbs unassisted; maintaining 20/40 vision and hearing acuity; working in a latex‑safe environment; maintaining good olfactory and tactile sensory function; qualified for respirator use.

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 or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need.

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