Clinical Documentation Improvement Pro

Duke Clinical Research Institute; Durham (NC); Remote; USD 80,000 - 100,000; Full time

Benefits offered by this job

Sign-on bonus $7500

Job summary

Duke Health, within the Patient Revenue Management Organization, seeks a Clinical Documentation Integrity Specialist to enhance the medical record's accuracy and completeness. You will interact with physicians, nursing staff, and case management to modify documentation for admission reasoning, severity, and mortality risk, while ensuring compliance with AHIMA and government standards.

You will compile findings, educate care teams, and participate in committees, contributing to accurate data

Qualifications

• Three years of progressive healthcare experience in an acute care setting.
• Experience with chart reviews, utilization review, or case management preferred.
• CCDS, CCS, or CDIP certifications are preferred.

Responsibilities

• Review clinical documentation and modify entries to reflect admission reason, service intensity, and conditions on admission.
• Coordinate with physicians and nursing staff to address documentation deficiencies and ensure regulatory compliance.
• Enter data into the CDI database and educate care teams on documentation quality improvements.

Skills

Communication skills

Critical thinking

Problem solving

Education

BSN or PA or NP or Doctorate

Tools

Computer skills

Job description

Duke Health, within the Patient Revenue Management Organization, seeks a Clinical Documentation Integrity Specialist to enhance the medical record's accuracy and completeness. You will interact with physicians, nursing staff, and case management to modify documentation for admission reasoning, severity, and mortality risk, while ensuring compliance with AHIMA and government standards.

You will compile findings, educate care teams, and participate in committees, contributing to accurate data