CDI Specialist: Elevate Care with Precise Documentation

Duke Clinical Research Institute; Mooresville (NC); Remote; USD 70,000 - 90,000; Full time

Benefits offered by this job

Relocation assistance

Job summary

Duke Health Lake Norman Hospital in Mooresville, NC seeks a Clinical Documentation Integrity Specialist to improve medical record quality through collaboration with physicians, nurses, and case management. You will review documentation, initiate chart reviews within 24-48 hours, educate care teams, and ensure accurate DRG, SOI/ROM, ICD-10 data, with ongoing education and adherence to AHIMA guidelines.

Bachelor's in Nursing or PA/NP or Doctorate, plus three years in acute care and strong

Qualifications

• Bachelor's degree required in nursing or physician assistant or NP or related doctorate field.
• Three years of progressive healthcare experience in an acute care setting.
• Experience with chart reviews and documentation improvement is preferred.

Responsibilities

• Review clinical documentation to reflect admission reason, service intensity, and prognosis.
• Initiate chart reviews within 24–48 hours of identification and monitor quarterly.
• Educate physicians, nurses, and case management on documentation requirements and AHIMA guidelines.
• Contribute to reports and implement documentation improvement initiatives.

Skills

Communication

Interpersonal skills

Critical thinking

Problem solving

Conflict management

Education

BSN

PA

NP

Doctorate

Job description

Duke Health Lake Norman Hospital in Mooresville, NC seeks a Clinical Documentation Integrity Specialist to improve medical record quality through collaboration with physicians, nurses, and case management. You will review documentation, initiate chart reviews within 24-48 hours, educate care teams, and ensure accurate DRG, SOI/ROM, ICD-10 data, with ongoing education and adherence to AHIMA guidelines.

Bachelor's in Nursing or PA/NP or Doctorate, plus three years in acute care and strong