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Durham, North Carolina, United States · On-site
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At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advanc…
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Full-time
bachelor degree, postgraduate degree
Relocation assistance, Commitment bonus
Posted 1d ago
~40 hrs/week
Remote in Durham, North Carolina, United States
Responsibilities
The Clinical Documentation Integrity Specialist facilitates modifications to medical records to ensure accurate clinical documentation of patient severity and risk of mortality. They also educate healthcare staff on documentation standards and reconcile DRG discrepancies to support accurate coding and revenue cycle functions.
Requirements
Candidates must hold a BSN, PA, NP, or a doctorate in a medically related field with at least three years of progressive acute care experience. Proficiency in clinical documentation improvement, chart review, and knowledge of regulatory compliance are essential.
Full job description
At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together.
Patient Revenue Management Organization
Pursue your passion for caring with the Patient Revenue Management Organization, which is the fully integrated, centralized revenue cycle organization that supports the entire health system in streamlining the revenue cycle. This includes scheduling, registration, coding, billing, and other essential revenue functions for Duke Health.
Duke Nursing Highlights:
Duke UniversityHealth System is designated as a Magnet organization
Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 Nurses.
Duke University Health System was awarded the American Board of Nursing Specialties Award for Nursing Certification Advocacy for being strong advocates of specialty nursing certification.
Duke University Health System has 6000 + registered nurses
Quality of Life: Living in the Triangle!
Relocation Assistance (based on eligibility)
This position comes with a one-time commitment bonus of $7500 that is paid in 2 equal installments over 12 months—6-month increments
Occ Summary
Clinical Documentation Integrity Specialists improve the overall quality and completeness of the medical record. Through concurrent interaction with physicians, nursing staff, case management, and medical records coding staff/compliance specialists, they facilitate modifications to clinical documentation to ensure accurate depiction of the level of clinical services, reason for admission, patient severity, risk of mortality, and conditions present on admission. Reviews the quality of medical record documentation and conveys deficiencies to house staff and the attending physician. Compiles and documents chart findings in a dedicated CDI database on a daily basis. Communicates with and educates members of the patient care team (physicians, advanced practice providers, patient resource managers, and case management) on an ongoing basis. Participates in select committees and provides education programs as necessary.
Work Performed
Reviews clinical documentation and facilitates modifications, as needed, to ensure that documentation accurately reflects the reason for admission, intensity of service rendered, risk of mortality, and conditions present on admission for all patients, in compliance with government and other regulations. Maintains a system to identify admissions for chart review Initiates chart review within 24-48 hours of identification Monitors the reviewed medical record every 48 hours to determine compliance with established documentation standards. Notifies the attending physician and house staff officers or other disciplines promptly of chart deficiencies requiring clarification, with a preference for face-to-face communication when practical.
Conducts follow-up reviews to ensure points of clarification have been addressed/recorded in the medical record and maintains an ongoing record of the results of each chart review, including responses to each intervention Serves as a resource to physicians and other members of the healthcare team in matters relating to published DRG, SOI/ROM, ICD-9, ICD-10, and PCS information. Maintains a level of practice demonstrating knowledge and understanding of AHIMA Practice Brief knowledge of compliance and regulatory agency expectations. Compiles and provides timely entry to the CDI database for statistical reporting.
Assists as necessary with review of the medical record post discharge to determine coding status. Completes timely retrospective review for unanswered concurrent queries ("No Response" queries) Reconciles DRG discrepancies collaboratively with the HIM team to ensure an accurate compilation of codes sent to the fiscal intermediary. Maintains awareness of post-discharge charts being held for completion of documentation deficiencies by the CDI department and is educated about the effect such charts have on Accounts Receivable work (DNFB). Maintains a consistent plan for follow-up and completion on such charts. Facilitates ongoing education of staff in chart documentation improvement techniques and practices. Provides periodic informal and formal in-service updates to medical staff and other disciplines on documentation issues using both one-on-one and group forums Develops and disseminates approved documentation improvement literature. Works with medical records, finance, and physician groups to develop work systems to facilitate complete documentation for data reporting purposes. Perform other related duties incidental to the work described herein.
Knowledge, Skills, and Abilities
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.
Level Characteristics
N/A
Minimum Qualifications
Education
BSN or PA (Physician's Assistant) or NP (Nurse Practitioner) or Doctorate degree in a medically related field is required.
Experience
Three years of progressive healthcare experience in an acute care setting. Previous chart review experience (case management utilization review) preferred. Excellent written/verbal communication, critical thinking, creative problem solving, and conflict management skills in addition to the proficient organization and planning skills required. Demonstrated knowledge of quality improvement theory and practice.
Degrees, Licensures, Certifications
Currently licensed and/or registered as a professional nurse/physician assistant/MD in the state of North Carolina, preferred. CCDS, CCS, or CDIP preferred.
Duke is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex (including pregnancy and pregnancy related conditions), sexual orientation or military status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Essential Physical Job Functions:
Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.
We put the person who needs our care at the center of everything we do.
Industry
Hospitals and Health Care
Company size
10,001+ employees
Founded
1925
Headquarters
Durham, North Carolina
LinkedIn followers
24,489
Duke University Hospital (DUH) is consistently rated as one of the best hospitals in the United States and is known around the world for its outstanding care and groundbreaking research.
Driven to bring extraordinary discoveries to fruition, deliver cutting edge clinical services to patients, and apply care and compassion to all stages of care, we maintain an unwavering focus on making the individuals and communities we serve healthier.
Today, DUH is the flagship of the Duke University Health System and a full-service, 957-bed, tertiary and quaternary academic medical center. Ranked nationally in 10 adult specialties by U.S. News and World Report for 2019-2020 and ranked first in North Carolina and first in the Raleigh-Durham area, care is delivered with inspiring passion and a deep commitment to put the person who needs our care at the center of everything we do.
Offices: 2301 Erwin Rd, Durham, North Carolina 27705, US
How many Administrative jobs are open in Durham, NC right now?
There are currently 864 open administrative positions in Durham, NC listed on Clera. New openings are added daily as companies post roles.
Which companies are hiring for Administrative roles in Durham, NC?
Companies currently hiring include Duke University School of Medicine, Duke University Hospital, Durham County Government, Duke Health Technology Solutions, Cintas, among others. Browse the listings above to see every active employer.
Are there remote or hybrid Administrative jobs in Durham, NC?
Yes — 140 of the 864 open administrative positions offer remote or hybrid work (57 remote, 83 hybrid).
How do I apply for Administrative jobs in Durham, NC?
Each listing links directly to the employer's application page. Apply early — fresh listings get the most recruiter attention in the first two weeks.