临床文件完整性专员 - 兼职 - 远程（Mooresville, NC, US）
Clinical Document Integrity Specialist - Part Time - Remote (Mooresville, NC, US
在杜克健康，我们致力于以充满同情心的护理改变患者、他们的亲人以及更广泛社区的生活。无论你的才能在哪里，加入我们，共同探索如何一起推进健康事业。
杜克健康湖诺曼医院
在北卡罗来纳州莫里斯维尔的杜克健康湖诺曼医院，追求你对护理的热情。作为四家杜克健康医院中床位最少的一家，共有123张床位，它提供全面的医疗服务，包括24小时急诊护理、心脏病学、骨科、女性健康服务和外科专科服务。
杜克护理亮点：
- 杜克大学医疗系统被授予护理卓越认证机构（Magnet）称号
- 每家医院的护士每年都会被评选为北卡罗来纳州“百名优秀护士”
- 杜克大学医疗系统因积极倡导专科护理认证，荣获美国护理专科委员会护理认证倡导奖
- 杜克大学医疗系统拥有6000多名注册护士
- 生活质量：生活在三角地区！
- 调职协助（根据资格）
*必须居住在以下任一州*
阿拉巴马州、亚利桑那州、加利福尼亚州、科罗拉多州、康涅狄格州、特拉华州、佛罗里达州、佐治亚州、夏威夷州、伊利诺伊州、印第安纳州、爱荷华州、肯塔基州、路易斯安那州、缅因州、马里兰州、马萨诸塞州、密歇根州、密苏里州、蒙大拿州、新罕布什尔州、新泽西州、纽约州、北卡罗来纳州、俄亥俄州、俄勒冈州、宾夕法尼亚州、南卡罗来纳州、田纳西州、德克萨斯州、弗吉尼亚州、华盛顿州、华盛顿特区
*部门核心工作时间是周一至周五早上6点至下午6点，但入职前90天内员工需工作早上8点至下午5点（兼职）。
*工作日时间为周一/周二/周四或周二/周四/周五，每周工作20小时，包含两天8小时工作和一天4小时工作。
职位描述
临床病历完整性专家通过与医生、护理人员、病例管理人员及病历编码/合规专家的实时互动，提高病历的整体质量和完整性。他们促进临床病历的修改，以确保准确反映临床服务等级、入院原因、患者病情严重程度、死亡风险以及入院时存在的状况。审查病历文档质量，并向住院医师和主治医师传达缺陷。每天将图表发现整理并记录到专用CDI数据库中。与相关人员沟通。
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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.
Duke Health Lake Norman Hospital
Pursue your passion for caring with Duke Health Lake Norman Hospital in Mooresville, North Carolina. The smallest of the four Duke Health hospitals at 123-beds, it offers a comprehensive range of medical services, including 24-hour emergency care, cardiology, orthopedics, women's services, and surgical specialties.
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)
*Must reside in one of the following states*
Alabama, Arizona, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Missouri, Montana, New Hampshire, New Jersey, New York, North Carolina, Ohio, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Washington (State), Washington, DC
*Dept core business hours are M-F between the hours of 6a - 6p, however during the 90-day orientation the employee would be working 8-5(Part time).
*Work day hours would either be M/T/Th or T/Th/Fri with two 8-hour days and one 4 hour day for the requisite 20 hours.
Job Description
Clinical Documentation Integrity Specialists improve 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 quality of medical record documentation and conveys deficiencies to house staff and attending physician. Compiles and documents chart findings in dedicated CDI database on a daily basis. Communicates with and educates members of the patient care team (physicians, advanced practice providers, patient resource managers, 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 reviews. Initiates chart review within 24-48 hours of identification Monitors the reviewed medical record every 48 hours to determine compliance to 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 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 AHIMA Practice Brief and knowledge of compliance and regulatory agency expectations. Compiles and provides timely entry to CDI database for statistical reporting. Assist 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 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 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
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
Bachelor’s in Nursing (BSN) or PA (Physician's Assistant) or NP (Nurse Practitioner) or Doctorate degree in a medically related field 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 required.
- Demonstrated knowledge of quality improvement theory and practice.
- Previous Clinical Documentation Integrity Specialists experience strongly preferred.
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 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 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.
Originally posted on Himalayas