Clinical Documentation Specialist I-RN

Job Description Summary

The RN – Clinical Documentation Specialist I reports to the Manager, Clinical Documentation. Under general supervision, the RN – Clinical Documentation Specialist I conducts reviews of inpatient electronic medical records to identify missing, vague, and/or incomplete diagnoses and facilitates appropriate physician documentation to accurately reflect patient severity of illness and risk of mortality. In collaboration with the medical staff, faculty and residents, HPA, UR, coding, HIS, Quality and the Center for Clinical Effectiveness, this role is charged with improving the quality of documentation for physicians and all caregivers.

Entity

Medical University Hospital Authority (MUHA)

Worker Type

Employee

Worker Sub-Type​

Regular

Cost Center

CC003762 COL - CDI Chart Documentation (DMC)

Pay Rate Type

Salary

Pay Grade

Health-28

Scheduled Weekly Hours

40

Work Shift

Job Description

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 Job Description

Minimum Requirements:

:

Bachelor's degree in Nursing from an accredited school of nursing and a minimum of (5) five years clinical nursing experience required.

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 relationship with diverse groups and individuals, medical staff and other health care disciplines; program and database development a plus.

Licensure a registered nurse by the South Carolina Board of Nursing or compact state.

Current American Heart Association (AHA) Basic Life Support (BLS) certification or American Red Cross BLS for Healthcare Providers certification is required.

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Physical Requirements:

NOTE: The following descriptions are applicable to this section: 1) Continuous – 6-8 hours per shift; 2) Frequent – 2-6 hours per shift;  3) Infrequent – 0-2 hours per shift

Ability to perform job functions while standing. (Frequent)

Ability to perform job functions while sitting. (Frequent)

Ability to perform job functions while walking. (Frequent)

Ability to climb stairs. (Infrequent)

Ability to work indoors. (Continuous)

Ability to work from elevated areas. (Frequent)

Ability to work in confined/cramped spaces. (Infrequent)

Ability to perform job functions from kneeling positions. (Infrequent)

Ability to bend at the waist. (Frequent)

Ability to squat and perform job functions. (Infrequent)

Ability to perform repetitive motions with hands/wrists/elbows and shoulders. (Frequent)

Ability to reach in all directions. (Frequent)

Possess good finger dexterity. (Continuous)

Ability to fully use both legs. (Continuous)

Ability to fully use both hands/arms. (Continuous)

Ability to lift and carry 15 lbs. unassisted. (Infrequent)

Ability to lift/lower objects 15 lbs. from/to floor from/to 36 inches unassisted. (Infrequent)

Ability to lift from 36 inches to overhead 15 lbs. (Infrequent)

Ability to maintain 20/40 vision, corrected, in one eye or with both eyes. (Continuous)

Ability to see and recognize objects close at hand or at a distance. (Continuous)

Ability to match or discriminate between colors. (Continuous)  *(Selected Positions)

Ability to determine distance/relationship between objects; depth perception. (Continuous)

Ability to maintain hearing acuity, with correction. (Continuous)

Ability to perform gross motor functions with frequent fine motor movements. (Continuous)

Ability to work in a latex safe environment. (Continuous)

*Ability to maintain tactile sensory functions. (Frequent)    *(Selected Positions)

*Ability to maintain good olfactory sensory function. (Frequent)  *(Selected Positions

*Ability to be qualified physically for respirator use, initially and as required. (Continuous)

(Selected Positions)*

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