Clinical Document Integrity Specialist - Part Time

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.

Pursue your passion for caring with Duke Health Lake Norman Hospital in Mooresville, North Carolina. The smallest of the four Duke Health hospitals at 123 beds, it offers a comprehensive range of medical services, including 24‑hour emergency care, cardiology, orthopedics, women's services, and surgical specialties.

• Duke University Health 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.
• Duke University Health System has 6,000+ registered nurses.
• Quality of Life:
  Living in the Triangle!
• Relocation Assistance (based on eligibility)

Alabama, Arizona, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Missouri, Montana, New Hampshire, New Jersey, New York, North Carolina, Ohio, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Washington (State), Washington, DC.

Clinical Documentation Integrity Specialists improve 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. The specialist reviews quality of medical record documentation and conveys deficiencies to house staff and attending physicians.

They compile and document chart findings in a dedicated CDI database on a daily basis, communicate with and educate members of the patient care team, and participate in select committees, providing education programs as necessary.

Reviews clinical documentation and facilitates modifications to ensure 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 reviews and initiates chart review within 24‑48 hours of identification. Monitors the reviewed medical record every 48 hours to determine compliance to established documentation standards, notifying the attending physician and house staff officers or other disciplines promptly of chart deficiencies with a preference for face‑to‑face communication when practical.

Conducts follow‑up reviews to ensure points of clarification have been addressed and maintains an ongoing record of each chart review, including responses. Serves as a resource to physicians and other members of the healthcare team regarding published DRG, SOI/ROM, ICD‑9, ICD‑10, and PCS information. Maintains knowledge of AHIMA Practice Brief and regulatory expectations. Compiles and provides timely entry to the CDI database for statistical reporting, assists with post‑discharge medical record review to determine coding status, completes retrospective review for unanswered concurrent queries, reconciles DRG discrepancies with the HIM team, and maintains awareness of post‑discharge chart holding status.

Facilitates ongoing education of staff in documentation improvement techniques and practices, provides informal and formal in‑service updates, and develops dissemination of approved documentation improvement literature. Works with medical records, finance and physician groups to develop work systems for complete documentation for data reporting. Performs other related duties incidental to the work described herein.

Prior…