Clinical Documentation Improvement Specialist
D
Duke HealthHealthcare
United StatesFull-TimeMiddle
SalaryOne-time commitment bonus of $7500 paid in 2 equal installments over 12 months
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Job Details
- Experience
- Three years of progressive healthcare experience in an acute care setting.
Requirements
- BSN, Physician's Assistant (PA), Nurse Practitioner (NP), or Doctorate degree in a medically related field.
- Three years of progressive healthcare experience in an acute care setting.
- Demonstrated knowledge of quality improvement theory and practice.
- Proficient organizational and planning skills.
- Strong computer skills for database management.
- Excellent written and verbal communication, critical thinking, and conflict management skills.
- Previous chart review or case management utilization review experience (preferred).
- Current licensure or registration as a professional nurse, physician assistant, or MD in North Carolina (preferred).
- CCDS, CCS, or CDIP certification (preferred).
Responsibilities
- Review clinical documentation and facilitate modifications to accurately reflect admission reasons, intensity of service, risk of mortality, and conditions present on admission.
- Monitor medical records every 48 hours to ensure compliance with documentation standards.
- Communicate chart deficiencies to physicians and care teams, preferably through face-to-face interactions.
- Conduct follow-up reviews to verify that documentation queries have been addressed and recorded.
- Serve as a resource for physicians regarding DRG, SOI/ROM, ICD-10, and PCS information.
- Reconcile DRG discrepancies collaboratively with the HIM team.
- Provide periodic education and updates to medical staff regarding documentation practices.
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