Clinical Document Integrity Specialist
New
D
Duke HealthHealthcare
Must reside in one of the following 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), Washington, DC, Dept core business hours are M-F between the hours of 6a - 6p; orientaion 8-5Part-TimeMiddle
Salary not disclosed
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Job Details
- Experience
- Three years of progressive healthcare experience in an acute care setting.
Requirements
- Bachelor’s degree in Nursing (BSN), Physician Assistant (PA) studies, Nurse Practitioner (NP) program, or a Doctorate in a medically related field.
- Minimum of three years of progressive healthcare experience in an acute care setting.
- Current licensure/registration as a Professional Nurse, Physician Assistant, or MD in the state of North Carolina is preferred.
- Previous chart review experience, such as case management or utilization review, is preferred.
- Previous experience as a Clinical Documentation Integrity Specialist is strongly preferred.
- Demonstrated knowledge of quality improvement theory and practice.
- Proficiency in DRG, SOI/ROM, ICD-9, ICD-10, and PCS documentation standards.
- Strong computer skills and proficiency in CDI database management.
- Excellent written and verbal communication, critical thinking, and conflict management skills.
- CCDS, CCS, or CDIP certification is preferred.
- Ability to work a part-time schedule of 20 hours per week, specifically M/T/Th or T/Th/Fri.
Responsibilities
- Facilitate clinical documentation modifications to accurately depict patient severity, risk of mortality, and conditions present on admission.
- Conduct concurrent chart reviews within 24-48 hours of identification and monitor records every 48 hours for compliance.
- Notify attending physicians and staff of documentation deficiencies and facilitate clarification.
- Maintain ongoing records of chart review results, intervention responses, and database entries for statistical reporting.
- Collaborate with the HIM team to reconcile DRG discrepancies and assist with post-discharge coding status reviews.
- Provide formal and informal in-service education to staff regarding documentation improvement techniques.
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