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.
Clinical Documentation Specialist I
Location
United States
Posted
3 days ago
Salary
0
Seniority
Mid Level
No structured requirement data.
Job Description
Clinical Documentation Specialist I
Medical University of South Carolina
Role 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. - Collaborate with and facilitate appropriate provider documentation to accurately reflect appropriate DRG (Diagnosis Related Group) assignment. - Assess patient severity of illness and risk of mortality. - Risk adjust for expected mortality/length of stay and clinically validate key diagnoses. The RN – Clinical Documentation Specialist I is responsible for: - A baseline understanding of interpreting quality metrics. - Participation in appropriate ICCE meetings, QAPIs, and/or other identified educational opportunities across the system. Qualifications - Bachelor's degree in nursing from an accredited school of nursing required. - At least five years' clinical nursing experience preferred. - Strong clinical experience and critical thinking skills required. - Extensive knowledge of patient care and clinical measurement tools. - 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. 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 - 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 Benefits - If you like working with energetic enthusiastic individuals, you will enjoy your career with us! Company Description 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.
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• This position is responsible for concurrent review of inpatient medical records in order to identify opportunities for improving the quality of physician documentation • Facilitates modifications to clinical documentation through concurrent interaction with physicians (face-to-face and electronically) and other members of the health care team • The goal of this position is to achieve a complete medical record in order to support complete, accurate and timely coding • Communicates with physicians, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients • Utilizes the hospital’s designated clinical documentation system to identify opportunities for physician and hospital outcomes • Provides or coordinates education to all internal customers related to compliance, coding, and clinical documentation issues and acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG • Responsible for the day-to-day evaluation of documentation by the medical staff and healthcare team in accordance with the hospital’s designated clinical documentation system • Gathers and analyzes information pertinent to documentation findings and outcomes • Contributes to a positive working environment and performs other duties as assigned or directed to enhance the overall efforts of the organization • Develops physician education strategies to promote complete and accurate clinical documentation and correct negative trends • Identifies patterns, trends variances and opportunities to improve documentation review and process • Researches literature and stays abreast of CMS rules and regulations, incorporating changes to daily practice for overall documentation enhancement • Assists in the development and reporting of performance measures to the medical staff and other departments and prepares physician specific data information • Conferences with key physicians to review outcome information (including physician profile data if relevant) as it relates to documentation clarity, completeness, and correct DRG designation • Coaches physicians to improve their documentation so it more accurately reflects intensity of services and severity of illness • Documents conference and results • Attends various hospital service line meetings, reviewing outcome information, and educating physicians on service line specific improvement opportunities • Complies with HIPAA and Code of Conduct policies • Assists with special projects as needed • Demonstrates competency for individual performance and development in the following areas: Customer Service, Job Skills, Resource Management, Teamwork, and Innovation • Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service • Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff
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