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CLINICAL DOCUMENTATION INTEGRITY SPEC
Job Title: CLINICAL DOCUMENTATION INTEGRITY SPEC
Job Code: 5515
FLSA: E
Job Level: G1
Revised Date: 11/01/2020
Supervisory Responsibility:
General Description of the Job Class
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.
Duties and Responsibilities of this Level
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 review
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 and regulatory agency expectations.
Compiles and provides timely entry to CDI database for statistical reporting.
Assists as necessary with review of the medical record post discharge to determine coding status.
Completes timely retrospective review for unanswered concurrent queries ("No Response" queries) Reconciles DRG discrepancies collaboratively with HIM team to ensure an accurate compilation of codes sent to fiscal intermediary.
Maintains awareness of post discharge charts being held for completion of documentation deficiencies by CDI department and is educated about the effect such charts have on Accounts Receivable work (DNFB). Maintains a consistent plan for follow up and completion on such charts.
Facilitates ongoing education of staff in chart documentation improvement techniques and practices.
Provides periodic informal and formal in-service updates to medical staff and other disciplines on documentation issues using both one-on- one and group forums
Develops and disseminates approved documentation improvement literature.
Works with medical records, finance and physician groups to develop work systems to facilitate complete documentation for data reporting purposes.
Perform other related duties incidental to the work described herein.
Required Qualifications at this Level
Education
BSN or PA (Physician's Assistant) or NP (Nurse Practitioner) or Doctorate degree in a medically related field required.
Experience
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.
Degrees, Licensure, and/or Certification
Currently licensed and/or registered as a Professional Nurse/Physician Assistant/MD in the state of North Carolina, preferred.
CCDS, CCS, or CDIP preferred.
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.
Distinguishing Characteristics of this Level
The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.
Duke University is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
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.
