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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 (physicians, advanced practice providers, patient resource managers, case management) on an ongoing basis.
• Participates in select committees and provides education programs as necessary.

Qualifications

• 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.

Requirements

• 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.
• 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

• Relocation Assistance (based on eligibility).
• Quality of Life: Living in the Triangle!