Registered Nurse (RN) - Clinical Documentation Lead

Palmatto Health Alliance   •  

Sumter, SC

Industry: Healthcare


5 - 7 years

Posted 170 days ago

This job is no longer available.


Bachelors Degree Required
BLS for Healthcare Providers required
5-8 years experience required

Job Summary:


To facilitate concurrent chart review in order to monitor effectiveness of documentation and physician queries. To participate with third party audit reviews and to perform closed chart reviews to determine and/or implement improvements.  To assist with on-going education for physicians and other care providers.  To collaborate with coders, case management and physicians to ensure accurate DRG assignment based on documentation.  To serve as a preceptor, education resource, and escalation point for the clinical documentation specialists. 


All team members are expected to be knowledgeable and compliant with Palmetto Health's values of compassion, dignity, excellence, integrity, and teamwork.



Performs concurrent documentation review of selected patient health records to clarify conditions, diagnoses, and procedures when conflicting or inadequate documentation is suspected.

Provides formal and point-of-care clinical documentation education sessions for physicians, nurses, and allied health professionals for complete and accurate documentation.

Serves as a preceptor, education resource and escalation point for clinical documentation specialists.

Collaborates with providers, coders, care givers to support the level of severity and clinical picture of patients and ensure accurate Diagnosis-Related Group (DRG) assignment based on documentation.

Monitors and evaluates effectiveness of concurrent chart reviews and physician query outcomes.

Performs monthly closed chart reviews as part of retrospective auditing and to define improvements opportunities.

Participates in third party audit reviews and assists with implementation of recommendations.

Assists in overall quality, timeliness, and completeness of the quality health record to ensure appropriate data, provider communication, and quality outcomes.


Education: Bachelor's degree in Nursing, Physical Therapy, Respiratory Therapy, Health Information Management, or related field. Work experience may NOT substitute for education requirement.

Experience: Five(5) years experience in adult medical/surgical/critical care/ER/PACU nursing, physical therapy, respiratory therapy, clinical documentation improvement, or inpatient coding and two(2) years experience as clinical documentation specialist.


Licensure, Registry, or Certification: Currently licensed or eligible to be licensed as a Registered Nurse (RN) in South Carolina by the South Carolina Board of Nursing,  currently licensed as a Physical Therapist (PT) by the South Carolina Board of Physical Therapy, currently registered as a Registered Respiratory Therapist (RRT) by the National Board for Respiratory Care (NBRC), currently credentialed as a Registered Health Information Technician (RHIT) by the American Health Information Management Association (AHIMA), currently credentialed as a Registered Health Information Administrator (RHIA) by AHIMA, or currently credentialed as a Certified Coding Specialist (CCS) by AHIMA. In addition, must also be Certified Clinical Documentation Specialist (CCDS) by the Association of Clinical Documentation Improvement Specialists (ACDIS) or Certified Documentation Improvement Practitioner (CDIP) by the American Health Information Management Association (AHIMA); Current BLS (Basic Life Support for Healthcare Providers) required prior to start date directly through the American Red Cross, the American Heart Association, or the military. (To register: Blended Learning or In Person BLS through the American Red Cross; or Classroom or Skills Session BLS through the American Heart Association. Certification must include an in-person skills session.)