Duke University Health System is a world-class, Magnet^®-designated health care network dedicated to providing outstanding patient care, educating tomorrow's health care leaders, and discovering new and better ways to treat disease through biomedical research. Duke University Health System is recognized as one of the top 100 places to work in health care.

Our Clinical Documentation Improvement professionals are exposed to robust institutional and physician support for quality documentation, access to an advanced electronic medical record system and state-of-the-art clinical documentation software. We are seeking qualified applicants for the following positions:

Clinical Documentation
Improvement Coordinator

Requirements:

• BSN, Physician's Assistant (PA) or Nurse Practitioner (NP) or Doctorate degree in a medically related field.
• Master's degree in Nursing or Health Care preferred.
• 5 years health care experience required.
• 3 years in acute health care delivery required.
• 2 years CDI experience required.
• CCDS/CDIP strongly preferred.
• RN with current North Carolina state license.

Responsibilities:

This position is responsible for the oversight and management of department operations and personnel. Specific duties include:

• Communicating with Coding Manager and CDI Director.
• Collaborating in planning, analysis, scheduling and related administrative duties.
• Monitoring and reporting of quality and financial performance in collaboration with Strategic Services Associate.

Clinical Documentation
Improvement Specialist

Requirements:

• BSN, Physician's Assistant (PA), Nurse Practitioner (NP) or Doctorate degree in a medically related field required.
• 3 years acute health care experience required.
• 2 years CDI experience preferred.
• CCDS, CDIP or CCS certification strongly preferred.
• RN with current North Carolina state license.

Responsibilities:

This position is responsible for improving overall quality and completeness of medical records. Specific responsibilities include:

• Facilitating modifications to clinical documentation, ensuring accurate depiction of the level of clinical services, reason for admission, patient severity, risk of mortality, severity of illness, and conditions present on admission.
• Reviewing medical record documentation for quality and ability to convey record deficiencies to house staff and attending physician for resolution.
• Compiling and documenting chart findings in dedicated CDI database on a daily basis.

This position is also responsible for reviewing overall quality and completeness of final reported codes. The Clinical Documentation Specialist reconciles differences in MS-DRG assignment through comparison and analysis of CDI patient summary to the final coding summary and medical record documentation. CDI will 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. CDI will also communicate with coders, compliance specialists and/or other clinical documentation analysts regarding documentation clarification and accurate coding.