Clinical Documentation Integrity Spec
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This position may have an opportunity to work remotely. All Duke University remote workers must reside in one of the following states or districts: Arizona; California; Florida; Georgia; Hawaii; Illinois; Maryland; Massachusetts; Montana; New Jersey; New York; North Carolina; Pennsylvania; South Carolina; Tennessee; Texas; Virginia or Washington, DC.
This position will be responsible for improving the overall quality and completeness of the medical record. Through interaction with physicians, nursing staff, medical records coding staff/compliance specialists, and other healthcare providers, they facilitate modifications to clinical documentation to ensure an 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. Reviews quality of medical record documentation and conveys deficiencies to house staff and attending physician. Compiles and documents chart findings in a dedicated CDI database on a daily basis.
Communicates with and educates members of the patient care team (physicians and advanced practice providers)and clinical documentation team on an ongoing basis. Participates in select committees and provides education programs as necessary. This position may also be responsible for reviewing the overall quality and completeness of coding by reconciling differences in the MS-DRGassignment through comparison and analysis of the coding summary and CDIpatient summary against medical record documentation. They 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. They also communicate with coders, compliance specialists, and/or clinical documentation analysts regarding documentation clarification and accurate coding.
Reviews clinical documentation and facilitates modifications, as needed, to ensure that documentation accurately reflects the reason for admission, the intensity of service rendered, risk of mortality, the severity of illness, and conditions present on admission for all patients, in compliance with government and other regulations. Maintains a system to identify discharges for chart review. Initiates chart review within 48-72 hours of identification. Notifies attending physician and house staff officers or other disciplines promptly of char 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 a resource to physicians and other members of the healthcare team in matters relating to published DRG, SOI/ROM , ICD-9, ICD-10 andPCS 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 the CDI database for statistical reporting.
Assists as necessary with the review of the medical record post-discharge to determine coding status. Completes timely retrospective review for unanswered queries (“No Response” queries). Reconciles DRG discrepancies collaboratively with HIMteam to ensure an accurate compilation of codes sent to the fiscal intermediary. Maintains awareness of post-discharge charts being held for the completion of documentation deficiencies by CDI department and is educated about the effect such charts have on Accounts Receivable (DNFB). Maintains a consistent plan for follow-up and completion on such charts. Facilitates ongoing education of staff in relation to 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 n improvement literature. Works with medical records, finance, and physician n groups to develop work systems to facilitate complete documentation for data reporting purposes. Evaluates variances in DRGs assigned by the CDI staff and collaborate with leadership across the System to support the educational needs of the CDI staff and Coders to ensure compliance with coding guidelines and identify opportunities for education. Perform other related duties incidental to the work described herein.
Knowledge, Skills, and Abilities
Prior Case Management / Utilization Review experience and/or trainingAdvancedcommunicationand 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.
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.
Duke 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.
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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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