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Clinical Documentation Improvement Spec
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)
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 theHIM-CDI staff suggests modifications to clinical documentation and coding to ensure accurate depiction of the level of clinical services, the reason for admission, patient severity, risk of mortality, the severity of illness, and conditions present on admission. Participates in select committees and provides education programs as necessary.
In this position, you are responsible for reviewing the overall quality and completeness of coding for expired and discharged to hospice encounters. They utilize current CMMS coding guidelines, conventions, and AHA coding clinics to accurately determine if the principal diagnosis, secondary diagnoses, and procedures reoccur ate so that we report the correct MS-DRG assignment. They also communicate with coders, compliance specialists, and/or clinical documentation analysts regarding documentation clarification and accurate coding, as needed.
BSN or PA (Physician's Assistant), NP (Nurse Practitioner), or Doctorate 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) is preferred. Excellent written/verbal communication, critical thinking, creative problem solving, conflict management skills, and proficient organization and planning skills are 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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Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob 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.
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