Clinical Document Integrity Specialist

🕒 August 6

🏈 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

👻 Ghost score 64%

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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 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 reflect 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, and case management staff • Participate in select committees and provide education programs • 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 and conduct follow-up reviews • Provide guidance on DRG, SOI/ROM, ICD-9, ICD-10, and PCS information • Enter CDI data for statistical reporting and perform retrospective reviews of unanswered queries • Reconcile DRG discrepancies with the HIM team • Track charts held for documentation completion and follow up on completion • Facilitate staff education and develop approved documentation improvement literature • Collaborate with medical records, finance, and physician groups to improve documentation systems • Perform other related duties

🎯 Requirements

• Must reside in one of the listed states: Alabama, Arizona, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Missouri, Montana, New Hampshire, New Jersey, New York, North Carolina, Ohio, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Washington (State), or Washington, DC • 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 (case management utilization review) preferred • 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 • Previous Clinical Documentation Integrity Specialist experience strongly preferred • Currently licensed and/or registered as a Professional Nurse, Physician Assistant, or MD in North Carolina preferred • CCDS, CCS, or CDIP preferred

🏖️ Benefits

• Magnet organization designation • Recognition through North Carolina's Great 100 Nurses • Relocation Assistance (based on eligibility)

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