Clinical Documentation Improvement Specialist

Jobtailor; Durham (NC); On-site; USD 70,000 - 100,000; Full time

Job summary

Jobtailor in Durham, NC is seeking a Clinical Documentation Improvement professional to enhance accuracy of hospital records. You will review admissions, coordinate chart reviews within 24–48 hours, and ensure compliance with documentation standards across departments.

The role requires a BSN/PA/NP or Doctorate in a medical field, with 3+ years in acute care and CM/UR experience. Strong communication and planning skills are essential; NC licensure is preferred, CCDS/CCS/CDIP are a plus.

Qualifications

• Three years of progressive healthcare experience in an acute care setting.
• Prior Case Management/Utilization Review experience and/or training.
• Advanced communication and interpersonal skills with all levels of internal and external customers.
• Proficient organization and planning skills.
• Currently licensed and/or registered as a professional nurse/physician assistant/MD in the state of North Carolina, preferred.
• CCDS, CCS, or CDIP preferred.

Responsibilities

• Review clinical documentation and facilitate modifications to accurately reflect reason for admission, intensity of service, risk of mortality, and conditions present on admission.
• Identify admissions for chart review and initiate review within 24–48 hours.
• Monitor reviewed medical records every 48 hours for compliance with documentation standards.
• Notify attending physicians, house staff, and other disciplines of chart deficiencies requiring clarification.
• Conduct follow-up reviews and maintain records of chart review results and intervention responses.
• Serve as a resource on DRG, SOI/ROM, ICD-9, ICD-10, and PCS information.
• Enter findings into the CDI database for statistical reporting.
• Review medical records post-discharge and complete retrospective reviews for unanswered concurrent queries.
• Reconcile DRG discrepancies with the HIM team.
• Follow up on charts held for documentation deficiencies and their impact on Accounts Receivable work.
• Facilitate staff education on documentation improvement techniques and provide in-service updates.
• Develop and disseminate approved documentation improvement literature.
• Work with medical records, finance, and physician groups to improve documentation systems.
• Participate in select committees and perform related duties.

Skills

Advanced communication skills

Critical thinking

Creative problem solving

Conflict management

Interpersonal skills

Strong computer skills

Organization and planning

Education

BSN

PA (Physician's Assistant)

NP (Nurse Practitioner)

Doctorate in a medically related field

Tools

CDI Database

Medical Records Systems

Job description

• Review clinical documentation and facilitate modifications to accurately reflect reason for admission, intensity of service, risk of mortality, and conditions present on admission
• Identify admissions for chart review and initiate review within 24–48 hours
• Monitor reviewed medical records every 48 hours for compliance with documentation standards
• Notify attending physicians, house staff, and other disciplines of chart deficiencies requiring clarification
• Conduct follow-up reviews and maintain records of chart review results and intervention responses
• Serve as a resource on DRG, SOI/ROM, ICD-9, ICD-10, and PCS information
• Enter findings into the CDI database for statistical reporting
• Review medical records post-discharge and complete retrospective reviews for unanswered concurrent queries
• Reconcile DRG discrepancies with the HIM team
• Follow up on charts held for documentation deficiencies and their impact on Accounts Receivable work
• Facilitate staff education on documentation improvement techniques and provide in-service updates
• Develop and disseminate approved documentation improvement literature
• Work with medical records, finance, and physician groups to improve documentation systems
• Participate in select committees and perform related duties

Requirements

• BSN, PA (Physician's Assistant), NP (Nurse Practitioner), or Doctorate degree in a medically related field is required
• Three years of progressive healthcare experience in an acute care setting
• 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
• Currently licensed and/or registered as a professional nurse/physician assistant/MD in the state of North Carolina, preferred
• CCDS, CCS, or CDIP preferred

Core Competencies

Demonstrates expertise in clinical documentation improvement, including knowledge of DRG, SOI/ROM, ICD-9, ICD-10, and PCS. Possesses strong communication, critical thinking, and organizational skills to enhance documentation accuracy and compliance in a healthcare setting.

Highest-signal resume keywords

• Clinical Documentation Improvement
• Case Management
• Utilization Review
• ICD-10 Knowledge
• Healthcare Compliance

ATS Optimization Keywords

Hard Skills

• Clinical Documentation Review
• Chart Review
• Statistical Reporting
• Quality Improvement
• Documentation Standards Monitoring

Soft Skills

• Advanced Communication Skills
• Critical Thinking
• Creative Problem Solving
• Conflict Management
• Interpersonal Skills

Certifications & Qualifications

• CCDS
• CCS
• CDIP

Industry Keywords

• Acute Care Setting
• Healthcare Experience
• Documentation Improvement Techniques
• Accounts Receivable
• North Carolina Nursing License

Tools & Technologies

• CDI Database
• Medical Records Systems