South Carolina RN Clinical Documentation Specialist

Job Summary

Conducting reviews of inpatient electronic medical records, the full-time salaried South Carolina RN Clinical Documentation Specialist will identify and address incomplete diagnoses, collaborate with providers for accurate documentation, and participate in quality metrics 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 for DRG assignment
• Participate in ICCE meetings and QAPIs to support quality metrics interpretation

Required qualifications

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