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.

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