Clinical Documentation Integrity Specialist

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.

Duke Health Lake Norman Hospital

Pursue your passion for caring with Duke Health Lake Norman Hospital in Mooresville, North Carolina. The smallest of the four Duke Health hospitals at 123-beds, it offers a comprehensive range of medical services, including 24-hour emergency care, cardiology, orthopedics, women's services, and surgical specialties.

Duke Nursing Highlights:

• 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 for being strong advocates of specialty nursing certification.
• Duke University Health System has 6000 + registered nurses
• Quality of Life: Living in the Triangle!
• Relocation Assistance (based on eligibility)

*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, however during the 90-day orientation the employee would be working 8-5(Part time).

*Work day hours would either be M/T/Th or T/Th/Fri with two 8-hour days and one 4 hour day for the requisite 20 hours.

Job Description

Clinical Documentation Integrity Specialists improve overall quality and completeness of the medical record. Through concurrent interaction with physicians, nursing staff, case management and medical records coding staff/compliance specialists, they facilitate modifications to clinical documentation to ensure accurate depiction of the level of clinical services, reason for admission, patient severity, risk of mortality and conditions present on admission. Reviews quality of medical record documentation and conveys deficiencies to house staff and attending physician. Compiles and documents chart findings in dedicated CDI database on a daily basis. Communicates with and educates members of the patient care team (physicians, advanced practice providers, patient resource managers, case management) on an ongoing basis. Participates in select committees and provides education programs as necessary.

Work Performed

Reviews clinical documentation and facilitates modifications, as needed, to ensure that documentation accurately reflects the reason for admission, intensity of service rendered, risk of mortality, and conditions present on admission for all patients, in compliance with government and other regulations. Maintains a system to identify admissions for chart reviews.  Initiates chart review within 24-48 hours of identification Monitors the reviewed medical record every 48 hours to determine compliance to established documentation standards. Notifies the attending physician and house staff officers or other disciplines promptly of chart deficiencies requiring clarification, with a preference for face-to-face communication when practical. Conducts follow-up reviews to ensure points of clarification have been addressed/recorded in the medical record and maintains an ongoing record of the results of each chart review including responses to each intervention Serves as resource to physicians and other members of the healthcare team in matters relating to published DRG, SOI/ROM, ICD-9, ICD-10 and PCS information. Maintains a level of practice demonstrating knowledge and understanding of AHIMA Practice Brief and knowledge of compliance and regulatory agency expectations. Compiles and provides timely entry to CDI database for statistical reporting. Assist as necessary with review of the medical record post discharge to determine coding status. Completes timely retrospective review for unanswered concurrent queries ("No Response" queries) Reconciles DRG discrepancies collaboratively with HIM team to ensure an accurate compilation of codes sent to fiscal intermediary. Maintains awareness of post discharge charts being held for completion of documentation deficiencies by CDI department and is educated about the effect such charts have on Accounts Receivable work (DNFB). Maintains a consistent plan for follow up and completion on such charts. Facilitates ongoing education of staff in chart documentation improvement techniques and practices. Provides periodic informal and formal in-service updates to medical staff and other disciplines on documentation issues using both one-on- one and group forums Develops and disseminates approved documentation improvement literature. Works with medical records, finance and physician groups to develop work systems to facilitate complete documentation for data reporting purposes. Perform other related duties incidental to the work described herein.

Knowledge, Skills and Abilities

• 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.

Level Characteristics

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.

Minimum Qualifications

Essential Physical Job Functions:

Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.

Education

Bachelor’s in Nursing (BSN) or PA (Physician's Assistant) or NP (Nurse Practitioner) or Doctorate degree in a medically related field required.

Experience

• 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 in addition to proficient organization and planning skills required.
• Demonstrated knowledge of quality improvement theory and practice.
• Previous Clinical Documentation Integrity Specialists experience strongly preferred.

Degrees, Licensures, Certifications

Currently licensed and/or registered as a Professional Nurse/Physician Assistant/MD in the state of North Carolina, preferred. CCDS, CCS, or CDIP preferred.