Clinical Document Integrity Specialist

This is a fully remote position, open to applicants in Alabama, +29 more states.

📋 Description

• Evaluate clinical documentation and facilitate adjustments to accurately represent the reason for admission, level of service, risk of mortality, and conditions present at the time of admission.

• Identify cases for chart review and initiate assessments within 24–48 hours.

• Monitor reviewed medical records every 48 hours to ensure compliance with documentation standards.

• Inform physicians and other relevant disciplines of chart deficiencies that need clarification.

• Conduct follow-up reviews and maintain records of interventions and their outcomes.

• Provide expertise on DRG, SOI/ROM, ICD-9, ICD-10, and PCS information.

• Enter CDI data for statistical analysis and reporting.

• Review medical records after discharge and complete retrospective reviews for unresolved concurrent queries.

• Reconcile DRG discrepancies with the HIM team.

• Follow up on charts flagged for documentation deficiencies and assess their impact on DNFB/Accounts Receivable.

• Educate staff and medical professionals on effective documentation improvement strategies and practices.

• Develop and distribute approved literature on documentation improvement.

• Collaborate with medical records, finance, and physician groups to enhance documentation systems.

• Participate in select committees and deliver educational programs.

⛳️ Requirements

• Applicants must reside in 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.

• A Bachelor’s degree in Nursing (BSN), Physician Assistant, Nurse Practitioner, or a doctorate degree in a medically related field is required.

• A minimum of three years of progressive healthcare experience in an acute care environment is necessary.

• Prior experience and/or training in Case Management / Utilization Review is required.

• Previous experience in chart review is preferred.

• Strong communication and interpersonal skills are essential.

• Excellent written and verbal communication, critical thinking, creative problem-solving, and conflict management abilities are required.

• Proficient organizational and planning skills are necessary.

• Strong computer skills are a must.

• Demonstrated understanding of quality improvement theory and practice is required.

• Previous experience as a Clinical Documentation Integrity Specialist is strongly preferred.

• Current licensure and/or registration as a Professional Nurse, Physician Assistant, or MD in North Carolina is preferred.

• CCDS, CCS, or CDIP certification is preferred.

• Must be able to work the required 20 hours per week with a schedule of either Monday/Tuesday/Thursday or Tuesday/Thursday/Friday, consisting of two 8-hour days and one 4-hour day.

• During the 90-day orientation, work hours will be from 8:00 AM to 5:00 PM.

🏝️ Benefits

• Relocation Assistance (based on eligibility).

• Quality of Life: Enjoy living in the Triangle!

• Duke University Health System is recognized as a Magnet organization.

• Nurses from each hospital are consistently acknowledged each year as North Carolina's Great 100 Nurses.

• Duke University Health System received the American Board of Nursing Specialties Award for Nursing Certification Advocacy.

• Access to a health system with over 6000 registered nurses.