South Carolina Licensed Clinical Documentation Specialist

Job Summary

To support pediatric inpatient care, the full-time South Carolina Licensed Clinical Documentation Specialist will conduct reviews of electronic medical records to identify documentation gaps and collaborate with healthcare providers to ensure accurate DRG assignment and patient severity assessment.

Key responsibilities

• Review inpatient electronic medical records to identify missing or incomplete diagnoses
• Collaborate with providers to facilitate accurate documentation reflecting patient severity and risk of mortality
• Participate in quality metrics interpretation and attend educational opportunities within the system

Required qualifications

• Bachelor's degree in nursing from an accredited institution
• Licensure as a registered nurse by the South Carolina Board of Nursing or compact state
• At least 5 years of nursing experience, with a minimum of 3 years in a Pediatric Inpatient or Emergency Department setting
• Strong clinical experience and critical thinking skills
• Extensive knowledge of patient care and clinical measurement tools