About This Role
This role is for a Registered Nurse who will work as a Clinical Documentation Specialist. The core of the job involves reviewing inpatient electronic medical records to pinpoint missing or incomplete diagnoses and collaborating with healthcare providers to ensure accurate documentation. This work directly impacts DRG assignments, patient severity of illness, and risk of mortality, while also involving clinical validation of key diagnoses and understanding quality metrics.
Responsibilities
- 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, patient severity of illness and risk of mortality
- Risk adjust for expected mortality/length of stay
- Clinically validate key diagnoses
- Understand how to interpret quality metrics
- Participate in appropriate ICCE meetings, QAPIs, and/or other identified educational opportunities across the system
Requirements
- Bachelor's degree in nursing from an accredited school of nursing
- Five years' clinical nursing experience preferred
- Strong clinical experience and critical thinking skills
- Extensive knowledge of patient care
- 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
Important Details
- Schedule: 40 scheduled weekly hours
- Physical requirements:
- Mobility & Posture: Continuous standing, sitting, walking, continuous working indoors; frequent working from elevated areas, working in confined/cramped spaces, twisting at the waist, squatting; infrequent climbing stairs, working outdoors, kneeling
- Manual Dexterity & Strength: Continuous pinching operations, gross motor use (fingers/hands), firm grasping (fingers/hands), fine manipulation (fingers/hands), repetitive motion (hands/wrists/elbows/shoulders), full use of both legs, tactile sensory function, gross motor with fine motor coordination; frequent reaching overhead, reaching in all directions, balance & coordination (lower extremities)
- Lifting & Force Requirements: Infrequent lift/carry 50 lbs. unassisted, lift/lower 50 lbs. from floor to 36”, lift up to 25 lbs. overhead; frequent exert up to 50 lbs. of force
- Vision & Sensory: Continuous maintain corrected vision 20/40 (one or both eyes), recognize objects (near/far), color discrimination, depth perception, peripheral vision, hearing acuity (with correction); continuous olfactory (smell) function and respirator use qualification for selected positions
