Clinical Document Integrity Specialist

🔥 1 minute ago

🏈 Alabama, Arizona, +27 more states – Remote

🏈 Alabama – Remote 🌵 Arizona – Remote 🏄 California – Remote ⛰️ Colorado – Remote 🦌 Connecticut – Remote 🐊 Florida – Remote 🌺 Hawaii – Remote 🌽 Illinois – Remote 🌾 Iowa – Remote 🐎 Kentucky – Remote ⚜️ Louisiana – Remote 🦞 Maine – Remote 🦬 Montana – Remote 🗻 New Hampshire – Remote 🏖️ New Jersey – Remote 🗽 New York – Remote 🌲 North Carolina – Remote 🏈 Ohio – Remote 🌲 Oregon – Remote 🦀 Maryland – Remote 🍂 Massachusetts – Remote 🚗 Michigan – Remote 🏰 Missouri – Remote 🔔 Pennsylvania – Remote 🌴 South Carolina – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⚔️ Virginia – Remote ☕ Washington – Remote

⏱ Part Time

🟡 Mid-level

🟠 Senior

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Duke University Health System

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

📚 Education

💰 $129.6k Grant on 2022-12

Healthcare • Education

Duke University Health System is an academic health system (branded Duke Health) that delivers clinical care, patient services, research and education across multiple integrated divisions. Its offerings include clinical laboratories, primary care, homecare & hospice, patient revenue management, health technology solutions, and transport services such as Duke Life Flight. The organization emphasizes advancing health through patient care, workforce development, and innovation—summarized by its mission “Advancing Health Together”—and is recognized for safety, quality, and employer culture.

📋 Description

• Improve the overall 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 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 daily in the CDI database • Educate physicians, advanced practice providers, patient resource managers, case management, and other patient-care team members • Identify admissions for chart review and initiate reviews within 24–48 hours • Monitor reviewed records every 48 hours for compliance with documentation standards • Notify physicians and other disciplines of deficiencies requiring clarification • Conduct follow-up reviews and maintain records of interventions and responses • Serve as a resource on DRG, SOI/ROM, ICD-9, ICD-10, and PCS information • Enter CDI data for statistical reporting • Review records post-discharge to determine coding status • Complete retrospective reviews for unanswered concurrent queries • Reconcile DRG discrepancies with the HIM team • Track charts held for documentation completion and follow up on completion • Facilitate staff education on documentation improvement practices • Provide formal and informal in-service updates to medical staff and other disciplines • Develop and disseminate approved documentation improvement literature • Collaborate with medical records, finance, and physician groups to improve documentation systems • Perform other related duties

🎯 Requirements

• Bachelor’s in Nursing (BSN), PA, NP, or doctorate degree in a medically related field required • Three years of progressive healthcare experience in an acute care setting • Previous chart review experience in case management/utilization review preferred • Excellent written and verbal communication skills • 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 • Previous Clinical Documentation Integrity Specialist experience strongly preferred • Current licensure and/or registration as a Professional Nurse, Physician Assistant, or MD in North Carolina preferred • CCDS, CCS, or CDIP certification preferred • Ability to work the department’s Monday–Friday, 6 a.m.–6 p.m. core business hours • During the 90-day orientation, work 8 a.m.–5 p.m. part time • Work either Monday/Tuesday/Thursday or Tuesday/Thursday/Friday, totaling 20 hours with two 8-hour days and one 4-hour day

🏖️ Benefits

• Duke University Health System is designated as a Magnet organization • Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 Nurses • Duke University Health System was awarded the American Board of Nursing Specialties Award for Nursing Certification Advocacy • Quality of Life: Living in the Triangle! • Relocation Assistance (based on eligibility) • Equal Opportunity Employer • Reasonable accommodation provisions available