South Carolina RN Clinical Documentation Specialist

Job Summary

South Carolina RN Clinical Documentation Specialist conducts reviews of inpatient electronic medical records to ensure accurate documentation and DRG assignment, working full-time in a salaried position.

Key Responsibilities

• Review inpatient electronic medical records to identify and rectify incomplete or vague diagnoses
• Collaborate with healthcare providers to ensure accurate documentation and risk adjustment
• Participate in quality metric interpretation and educational opportunities within the system

Required Qualifications and Education

• Bachelor's degree in nursing from an accredited institution
• Minimum of five years clinical nursing experience preferred
• Licensure as a registered nurse by the South Carolina Board of Nursing or compact state
• Current American Heart Association (AHA) Basic Life Support (BLS) certification required
• Strong clinical experience and critical thinking skills are essential