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Role 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 on an ongoing basis.
• Participates in select committees and provides education programs as necessary.
Work Performed
• Reviews clinical documentation and facilitates modifications to ensure compliance with 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 for compliance.
• Notifies the attending physician and house staff of chart deficiencies requiring clarification.
• Conducts follow-up reviews to ensure points of clarification have been addressed.
• Serves as a resource to physicians and healthcare team members regarding DRG, SOI/ROM, ICD-9, ICD-10, and PCS information.
• Maintains knowledge of compliance and regulatory agency expectations.
• Compiles and provides timely entry to CDI database for statistical reporting.
• Assists with review of the medical record post-discharge to determine coding status.
• Completes timely retrospective review for unanswered concurrent queries.
• Reconciles DRG discrepancies with HIM team for accurate coding compilation.
• Maintains awareness of post-discharge charts held for documentation deficiencies.
• Facilitates ongoing education of staff in chart documentation improvement techniques.
• Provides periodic informal and formal in-service updates on documentation issues.
• Develops and disseminates approved documentation improvement literature.
• Works with medical records, finance, and physician groups to develop work systems for complete documentation.
• Performs 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.
Minimum Qualifications
• 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 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.
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.