Clinical Documentation Improvement Specialist

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🌲 North Carolina – Remote

🌲 North Carolina – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

👻 Ghost score 13%

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Duke Careers

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1924

💼 Consulting

🏥 Healthcare

📚 Education

Consulting • Healthcare • Education

Duke Careers is a platform connected to Duke University's rich legacy, established in 1924. It aims to celebrate the centennial of Duke University while providing resources, stories, and interviews that reflect the university's history, current achievements, and future aspirations. A key focus of Duke Careers is to engage with alumni and the community, showcasing the transformative impact of education and leadership within the university.

📋 Description

• Improve the quality and completeness of medical records • Interact concurrently with physicians, nursing staff, case management, medical records coding staff, and compliance specialists • Facilitate documentation modifications to accurately depict level of clinical services, reason for admission, patient severity, risk of mortality, and conditions present on admission • Review medical record documentation and communicate deficiencies to house staff and attending physicians • Compile and document chart findings in the CDI database daily • Educate physicians, advanced practice providers, patient resource managers, and case management staff • Review charts within 24–48 hours of identification and monitor records every 48 hours • Conduct follow-up reviews and maintain records of clarification interventions • Serve as a resource on DRG, SOI/ROM, ICD-9, ICD-10, and PCS information • Perform retrospective reviews, reconcile DRG discrepancies with the HIM team, and support documentation completion • Provide formal and informal education on documentation improvement techniques • Develop and disseminate approved documentation improvement literature • Collaborate with medical records, finance, and physician groups to improve documentation systems and data reporting • Participate in select committees and perform related duties

🎯 Requirements

• BSN, PA (Physician's Assistant), NP (Nurse Practitioner), or Doctorate degree in a medically related field is required • Three years of progressive healthcare experience in an acute care setting • Prior Case Management/Utilization Review experience and/or training • Advanced communication and interpersonal skills with all levels of internal and external customers • Excellent written/verbal communication, critical thinking, creative problem solving, and conflict management skills • Proficient organization and planning skills • Strong computer skills • Demonstrated knowledge of quality improvement theory and practice • Currently licensed and/or registered as a professional nurse/physician assistant/MD in the state of North Carolina, preferred • CCDS, CCS, or CDIP preferred • Previous chart review experience (case management utilization review) preferred

🏖️ Benefits

• Relocation Assistance (based on eligibility) • One-time commitment bonus of $7500, paid in 2 equal installments over 12 months at 6-month increments • Magnet organization environment • Specialty nursing certification advocacy and support • Equal opportunity and nondiscrimination commitment • Reasonable accommodation support