CLINICAL DOCUMENTATION IMPROVEMENT SPEC

  • Requisition Number: 2073
  • Department: PRMO
  • Location: Durham
  • Type of Position: Regular
  • Apply

 

PRMO:, established in 2001, Patient Revenue Management Organization (PRMO) is a fully integrated, centralized revenue cycle organization supporting all of Duke Health, including Duke University Hospital, Duke Regional Hospital, Duke Raleigh Hospital, the Private Diagnostic Clinic, and Duke PrimaryCare. The PRMO focuses on streamlining the revenue cycle through enhanced management of scheduling, registration, coding, HIM operations, billing, collections, cash management, and customer service. The Mission of the PRMO is delivering quality service by enhancing the patient experience, providing financial security, and preserving Duke’s reputation and mission of advancing health together. Our Vision is to be recognized as a world class innovative revenue cycle organization that values our people, patients and performance.

 

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!

 

Duke University Health System - Patient Revenue Management Office (PRMO) seeks to hire an experienced Clinical Documentation Improvement Specialist who will embrace our mission of Advancing Health Together.

Work Hours & Shifts
Full Time: Day Shift

Highlights:
* Career-forward opportunity with a nationally-ranked health system
* Quality of Life: Living in the Triangle
* Best in class benefit package
* Tuition Reimbursement for continuing education

Job Summary:
Our Clinical Documentation Improvement professionals are exposed to robust institutional and physician support for quality documentation, access to an advanced electronic medical record system and state-of-the-art clinical documentation software. Currently, we are conducting a national search to identify clinical documentation professionals who would like to continue their career with Duke University Health System.
This position is responsible for improving overall quality and completeness of medical records.

Specific responsibilities include:
* Through interaction with physicians, nursing staff, medical records coding staff/compliance specialists and other healthcare providers, clinical documentation analysts facilitate modifications to clinical documentation ensuring accurate depiction of the level of clinical services, reason for admission, patient severity, risk of mortality, severity of illness and conditions present on admission.
* Review medical record documentation for quality and possess ability to convey deficiencies to house staff and attending physician for resolution.
* Compile and document chart findings in dedicated CDI database on a daily basis.
* Communicate with and educate members of the patient care team (physicians and advanced practice providers) and others on the clinical documentation concepts on an ongoing basis.
* Participation on select committees and providing educational programs as necessary.

* This position may also be responsible for reviewing overall quality and completeness of coding by reconciling differences in the MS-DRG assignment through comparison and analysis of the coding summary and CDI patient summary against medical record documentation.

* You will utilize current CMS coding guidelines, conventions and AHA coding clinics to accurately determine the principal and secondary diagnoses and procedures that affect the MS-DRG assignment.

* You will also communicate with coders, compliance specialists and/or clinical documentation analysts regarding documentation clarification and accurate coding.

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

Experience:
3 years of relevant experience and appropriate certifications.  For Nurses case management or utilization review and acute care clinical experience is preferred. 

For a position focused on reconciliation, two of the three years must have Clinical Documentation / DRG assignment and validation/coding in a CDI program.

Degrees, Licensures, Certifications
Current licensure as an RN, NP, PA or licensure in the specific medical field associated with a Doctorate degree.  CCDS or CDIP or CCS certification preferred for non-nurses.
 

 

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.