South Carolina Licensed Clinical Documentation Specialist

Job Summary

Reporting to the Clinical Documentation Manager, the full-time South Carolina Licensed Clinical Documentation Specialist will conduct reviews of inpatient electronic medical records to identify and rectify incomplete diagnoses, ensuring accurate documentation for DRG assignment and patient risk assessment, while participating in quality metric interpretation and educational opportunities.

Key responsibilities

• Review inpatient electronic medical records to identify missing or vague diagnoses
• Collaborate with healthcare providers to ensure accurate documentation reflecting patient severity and risk of mortality
• Participate in ICCE meetings and quality assurance initiatives to interpret and improve clinical metrics

Required qualifications

• Bachelor's degree in nursing from an accredited institution
• Licensure as a registered nurse by the South Carolina Board of Nursing or a compact state
• At least five years of clinical nursing experience preferred
• Strong clinical experience and critical thinking skills
• Extensive knowledge of clinical measurement tools and patient care outcomes