Clinical Document Integrity Specialist - Part Time - Remote (Mooresville, NC, US

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.
Duke Health Lake Norman Hospital

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 Nursing Highlights:

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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.

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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.

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Duke University Health System has 6000 + registered nurses

- Quality of Life: Living in the Triangle!

- Relocation Assistance (based on eligibility)

*Must reside in one of the following states*

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

*Dept core business hours are M-F between the hours of 6a - 6p, however during the 90-day orientation the employee would be working 8-5(Part time).

*Work day hours would either be M/T/Th or T/Th/Fri with two 8-hour days and one 4 hour day for the requisite 20 hours.
Job Description

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. Reviews quality of medical record documentation and conveys deficiencies to house staff and attending physician. Compiles and documents chart findings in dedicated CDI database on a daily basis. Communicates with and educates members of the patient care team (physicians, advanced practice providers, patient resource managers, 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 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, 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 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 and knowledge of compliance