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Clinical Document Integrity Specialist
Duke University Health SystemClinical Document Integrity Specialist at Duke Health improving medical record quality and completeness. Collaborating with healthcare staff to ensure documentation accuracy for patient care in North Carolina.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Clinical Documentation Integrity, ensuring accurate representation of patient admissions and services rendered. Proficient in chart review processes, compliance monitoring, and effective communication with healthcare teams.
Highest-signal resume keywords
Clinical Documentation IntegrityChart Review ExperienceQuality Improvement KnowledgeCritical Thinking SkillsLicensed Professional Nurse
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
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Hard Skills
Chart ReviewClinical DocumentationICD-9 CodingICD-10 CodingPCS CodingDRG KnowledgeSOI/ROM KnowledgeStatistical ReportingCompliance MonitoringHealthcare Documentation Standards
Soft Skills
Written CommunicationVerbal CommunicationCreative Problem SolvingConflict ManagementOrganizational Skills
Tools & Technologies
CDI Database
Certifications & Qualifications
CCDSCCSCDIP
Industry Keywords
Acute Care SettingHealthcare ExperienceClinical Documentation Integrity SpecialistNursingPhysician AssistantNurse Practitioner
About the role
Key responsibilities & impact- Reviews clinical documentation and facilitates modifications 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.
- Maintains a system to identify admissions for chart reviews.
- Initiates chart review within 24-48 hours of identification.
- Monitors the reviewed medical record every 48 hours to determine compliance to established documentation standards.
- Notifies the attending physician and house staff officers or other disciplines promptly of chart deficiencies requiring clarification.
- Conducts follow-up reviews to ensure points of clarification have been addressed in the medical record.
- Maintains ongoing record of the results of each chart review.
- Serves as resource to physicians and other healthcare team members for published DRG, SOI/ROM, ICD-9, ICD-10 and PCS information.
- Compiles and provides timely entry to CDI database for statistical reporting.
- Assists with review of the medical record post discharge to determine coding status.
Requirements
What you’ll need- Bachelor’s in Nursing (BSN) or PA (Physician's Assistant) or NP (Nurse Practitioner) or Doctorate degree in a medically related field required.
- 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 proficient organization and planning skills required.
- Demonstrated knowledge of quality improvement theory and practice.
- Previous Clinical Documentation Integrity Specialists experience strongly preferred.
- Currently licensed and/or registered as a Professional Nurse/Physician Assistant/MD in the state of North Carolina, preferred. CCDS, CCS, or CDIP preferred.
Benefits
Comp & perks- Quality of Life: Living in the Triangle!
- Relocation Assistance (based on eligibility)