CLINICAL DOCUMENTATION INTEGRITY SPEC

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.

About Duke Health's Patient Revenue Management Organization

Pursue your passion for caring with the Patient Revenue Management Organization, which is Duke Health's 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.

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)

Occ Summary

Clinical Documentation Integrity Specialists 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, they 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. Reviews the quality of medical record documentation and conveys deficiencies to house staff and the attending physician. Compiles and documents chart findings in the dedicated CDI database on a daily basis. Communicates with and educates members of the patient care team (physicians, advanced practice providers, patient resource managers, and case management) on an ongoing basis. Participates in select committees and provides education programs as necessary.

Work Performed

Reviews clinical documentation and facilitates 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. Maintains a system to identify admissions for chart review. Initiates chart review within 24-48 hours of identification. Monitors the reviewed medical record every 48 hours to determine compliance with established documentation standards.

Notifies 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. 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, and PCS information. Maintains a level of practice demonstrating knowledge and understanding of the 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 review of the medical record post-discharge to determine coding status. Completes timely retrospective review for unanswered concurrent queries ("No Response" queries). 

Reconciles DRG discrepancies collaboratively with the HIM team to ensure an accurate compilation of codes sent to fiscal intermediary. Maintains 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). Maintains a consistent plan for follow-up and completion on such charts. Facilitates ongoing education of staff in 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 improvement literature. Works 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.

Knowledge, Skills and Abilities

Prior Case Management/Utilization Review experience and/or training Advanced communication and 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.

Level Characteristics

Prior Case Management/Utilization Review experience and/or training Advanced communication and 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.

Minimum Qualifications

Duke is an 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 (including pregnancy and pregnancy related conditions), sexual orientation or military 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 areheard. 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.

Education

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

Experience

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 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.