Clinical Documentation Improvement spec

Duke University Health System
June 30, 2022
United States
Job Type
Work Setting


This position will be responsible for improving the overall quality and completeness of the medical record through CMS and Vizient reviews. Through interaction with medical records coding staff and compliance specialists, the HIM-CDI staff suggests modifications to clinical documentation and coding to ensure an accurate depiction of the level of clinical services, the reason for admission, patient severity, risk of mortality, and severity of illness and conditions present on admission. Participates in select committees and provides education programs as necessary.

This position is responsible for reviewing the overall quality and completeness of coding for expired and discharge to hospice encounters. They utilize c urrentCMS coding guidelines, conventions, and AHA coding clinics to accurately determine if the principal diagnosis, secondary diagnoses, and procedures are accurate so that we report the correct MS-DRG assignment. They also communicate with coders, compliance specialists, and/or clinical documentation analystsregarding documentation clarification and accurate coding, as needed.

Minimum Qualifications


BSN or PA (Physician's Assistant) or NP (Nurse Practitioner) or Doctorate degree in a medically related field is 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.

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.

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