Remote Utilization Review Nurse Jobs in Raleigh, NC

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.

Patient Revenue Management Organization

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

Duke Nursing Highlights:

• Duke UniversityHealth 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)

This position comes with a one-time commitment bonus of $7500 that is paid in 2 equal installments over 12 months-6-month increments

This position will be responsible for utilizing their clinical/nursing knowledge, and understanding of current CMS coding guidelines, conventions and AHA coding clinics to improve the overall quality and completeness of the patient medical record. Through a multidisciplinary team process, the Ambulatory CDI Specialist performs pre-visit and retrospective reviews of ambulatory clinical documentation to ensure accurate depiction of the true complexity of the patient. This includes compliant documentation to support the capture or Hierarchical Condition Categories (HCC), ICD-10-CM accuracy and specificity, and medical necessity. They work collaboratively with ambulatory physicians and advanced practice providers to communicate opportunities and educate members of the patient care team regarding documentation guidelines, coding requirements and service-line specific requirements. They also communicate with coders, compliance specialists and/or clinical documentation analysts regarding documentation clarification and accurate coding, as needed. Participates in select committees and provides education programs as necessary. 

(25%) 1. Medical Record Review: Performs pre-visit and retrospective reviews to ensure appropriate clinical documentation to support Hierarchical Condition Categories, ICD-10-CM specificity and medical necessity of ambulatory visits. Follows Ambulatory CDI processes for performing medical record reviews, identifying opportunities to improve provider documentation and querying physicians as needed to ensure that appropriate documentation appears in the medical record. Consistently meets established productivity targets for record review.

(20%) 2. Competency: Demonstrates knowledge of documentation requirements and coding guidelines that pertain to outpatient diagnosis coding to accurately reflect the complexity and medical necessity of the visit. Analyzes clinical status of patients, current treatment plan and past medical history and identifies potential gaps in physician documentation. Maintains a level of practice demonstrating knowledge and understanding of outpatient query standards and knowledge of compliance and regulatory agency expectations.

(20%) 3. Education: Routinely provides education to physicians, advanced practice providers and other key healthcare providers regarding the need for accurate, specific, and complete clinical documentation in the patient's medical record. Delivers provider specific metrics and coach providers on problem list and RAF gap closing opportunities as needed.

(20%) 4. Collaboration: Collaborates effectively throughout the organization by developing collegial relationships and communicating information effectively, encouraging communication and serving as a resource to staff and other departments. Communicates with clinic and coding staff as needed regarding documentation concerns and assists with resolving queries. Reviews data and trends to help identify opportunities, offer solutions, and participate in their resolution.

(10%) 5. Professional Growth and Development: Demonstrates responsibility and accountability for personal development by participating in continuing education offerings. Maintains competence related to HCC documentation requirements, ICD-10-CM code assignment and coding guidelines.

(5%) 6. All other duties as assigned.

Education:

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

Experience:

3 years of relevant experience.
Ambulatory nursing or clinical experience (Preferred)

Experience with Medicare risk adjustment, Hierarchical Condition Categories, coding, billing, auditing (Preferred)

Degrees, Licensure, and/or Certification:

Current licensure as an RN, NP, PA or licensure in the specific medical field associated with a Doctorate degree required.

Current Certification in Clinical Documentation Improvement (CDIP, CCDS, CCDS-O or CDEO) highly preferred or appropriate certification within 2 years of employment.
Certification in medical coding and or risk adjustment (i.e. CRC, CPC, CCS, or CCS-P or other pertinent to outpatient) preferred.

Knowledge, Skills, and Abilities:

Extensive Outpatient CDI and Risk Adjustment Coding knowledge
Effective written and verbal communication, presentation and training skills
Excellent critical thinking, creative problem solving and conflict management skills
Proficient organization and planning skills.
Strong computer and statistical reporting skills.
PowerPoint, Excel, 3M software, and Encoder experience.
Demonstrated knowledge of quality improvement theory and practice. 
Works independently with minimal supervision

The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform job-related tasks other than those specifically presented in this description.

Duke University 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.

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.

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.