Clinical Documentation Integrity Specialist-Commitment Bonus

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 Primary Care. 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 (based on eligibility)

 

Commitment Bonus: $10,000 (4 equal installments over 24 months in 6-month increments)

 

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.

 

Occ Summary

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 physicians. Compiles and documents chart findings in a dedicated CDI database daily.

 

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 patient 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.

 

Work Performed

 

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 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 the review of the medical record post-discharge to determine coding status. Completes tim