CLINICAL DOCUMENTATION IMPROVEMENT SPEC

Duke Careers • Durham, NC

22h • Onsite

About The Position

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. Patient Revenue Management Organization Pursue your passion for caring with the Patient Revenue Management Organization, which is the fully integrated, centralized revenue cycle organization that supports the entire health system in streamlining the revenue cycle. This includes scheduling, registration, coding, billing, and other essential revenue functions for Duke Health. Duke Nursing Highlights: 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. 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. Duke University Health System has 6000 + registered nurses Quality of Life: Living in the Triangle! Relocation Assistance (based on eligibility)

Requirements

• 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.
• Proficient organization and planning skills.
• Demonstrated knowledge of quality improvement theory and practice.
• Currently licensed and/or registered as a professional nurse/physician assistant/MD in the state of North Carolina, preferred.
• CCDS, CCS, or CDIP preferred.

Nice To Haves

• Prior Case Management / Utilization Review experience and/or training
• Advanced communication and interpersonal skills with all levels of internal and external customers.
• Strong computer skills.

Responsibilities

• Improve the overall quality and completeness of the medical record through concurrent interaction with physicians, nursing staff, case management and medical records coding staff/compliance specialists.
• 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.
• Review the quality of medical record documentation and convey deficiencies to house staff and attending physician.
• Compile and document chart findings in a dedicated CDI database on a daily basis.
• Communicate with and educate members of the patient care team (physicians, advanced practice providers, patient resource managers, and case management) on an ongoing basis.
• Participate in select committees and provide education programs as necessary.
• Review clinical documentation and facilitate 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.
• Maintain a system to identify admissions for chart review.
• Initiate chart review within 24-48 hours of identification.
• Monitor the reviewed medical record every 48 hours to determine compliance with established documentation standards.
• Notify 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.
• Conduct follow-up reviews to ensure points of clarification have been addressed/recorded in the medical record and maintain an ongoing record of the results of each chart review, including responses to each intervention.
• Serve as a 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.
• Maintain a level of practice demonstrating knowledge and understanding of AHIMA practices.
• Compile and provide timely entry to the CDI database for statistical reporting.
• Assist as necessary with review of the medical record post-discharge to determine coding status.
• Complete timely retrospective review for unanswered concurrent queries ("No Response" queries).
• Reconcile DRG discrepancies collaboratively with the HIM team to ensure an accurate compilation of codes sent to the fiscal intermediary.
• Maintain awareness of post-discharge charts being held for completion of documentation deficiencies by the CDI department and is educated about the effect such charts have on accounts receivable work (DNFB).
• Maintain a consistent plan for follow-up and completion on such charts.
• Facilitate ongoing education of staff in chart documentation improvement techniques and practices.
• Provide periodic informal and formal in-service updates to medical staff and other disciplines on documentation issues using both one-on-one and group forums.
• Develop and disseminate approved documentation improvement literature.
• Work 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.

Benefits

• Relocation Assistance (based on eligibility)

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 101-250 employees