Clinical Documentation Quality Specialist

Duke Health; Mooresville (NC); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Relocation Assistance (based on elig)

Job summary

Duke Health Lake Norman Hospital in Mooresville, NC seeks a Clinical Documentation Integrity Specialist to enhance the accuracy of medical records and support the integrity of DRG coding. The role collaborates with physicians, nursing staff, case management and coding to optimize documentation and compliance.

Responsibilities include conducting concurrent chart reviews, educating care teams, and maintaining documentation improvement processes to ensure high-quality data for reporting and

Qualifications

• Bachelor’s in Nursing (BSN) or PA/NP or Doctorate in a medically related field.
• Three years of progressive healthcare experience in an acute care setting.
• Previous chart review experience (case management/utilization review) preferred.

Responsibilities

• Review clinical documentation and facilitate modifications to accurately reflect admission reason, intensity of service, and conditions present.
• Identify admissions for chart reviews and initiate chart review within 24–48 hours.
• Educate physicians and care teams on documentation issues and regulatory expectations.

Skills

Case management

Utilization review

Communication

Quality improvement

Education

BSN or PA/NP/Doctorate

Job description

Duke Health Lake Norman Hospital in Mooresville, NC seeks a Clinical Documentation Integrity Specialist to enhance the accuracy of medical records and support the integrity of DRG coding. The role collaborates with physicians, nursing staff, case management and coding to optimize documentation and compliance.

Responsibilities include conducting concurrent chart reviews, educating care teams, and maintaining documentation improvement processes to ensure high-quality data for reporting and