Clinical Documentation Specialist I

Job Description Summary

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

CC004847 ORBG - Quality Assurance

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 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.  

• 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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