Medical Records Nurse
5 months ago
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 HomeCare & Hospice
Pursue your passion for caring with Duke HomeCare & Hospice, which offers hospice, home health, and infusion services across the region, as well as serves as the home forthe Duke Caregiver Support Program. Team members work closely with a patient's physician to provide comprehensive, individualized care in the comfort of their home or at our inpatient hospice facility in Durham, NC.
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
Relocation Assistance (based on eligibility)
Shift: Monday-Friday 8:30AM-5:00PM
Duke HomeCare and Hospice differs from other home health companies in many amazing ways. No call or weekend requirements
# Mileage reimbursement rate equal to the current federal rate
# Performs professional nursing care for patients in a primary care setting (the home or alternate site setting) according to nursing practices, agency policies and regulations. Provide nursing services to patients and families in accordance with the scope of the RN as defined by the North Carolina Board of Nursing.
Plan, provide, supervise and document professional nursing care utilizing the nursing process for patients in accordance with the NC nurse practice act, physician orders and established policies and procedures. Uses professional nursing judgment to individualize the plan of care based on assessment of the patient’s baseline needs and response to care.
# collaborate with healthcare team in the evaluation and cost effectiveness of patient care.
# Assess educational needs of patients/families concerning alterations in health, the disease process, and plan of care.
# Role model professional nursing through conduct, appearance, communication, mutual respect, ethical decision-making, critical thinking, and problem-solving skills.
# Participate in weekly interdisciplinary team meetings and case conferences, as necessary, to assure appropriate care and service are provided to the patient.
# Maintain up to date knowledge of Medicare/Medicaid/JCAHO standards thru inservices and workshop attendance.
# Document care and services provided in accordance with DHCH Policy and Procedures and regulatory standards.
# Medication reconciliation and education to prevent adverse events and readmission to hospital
# Follow infection control standard precautions and uses personal protective equipment as required.
# Delegate and supervise care given by NCA’s/LPN’s.
# Develop plan of care for aides, assign care to aides based on the skills of the aide, the availability of the aide for patient care continuity, patient preference (when possible), and other considerations as determined by the patient’s care needs.
# Identify personal learning needs and implements corrective action: assists in planning and conducting staff development programs to improve DHCC effectiveness.
# Participate in own professional development by maintaining required competencies, identifying learning needs and seeking appropriate assistance or educational offerings.
# Implement agency policy, procedures and objectives.
# Work closely and collaboratively with agency billing staff to ensure accuracy of billing.
# Participate in Performance Improvement Program.
# Promote quality, comprehensive services through a team approach.
# Home Health
Complete required OASIS Comprehensive assessments at admission, recertification, Resumption of care and discharge. This assessment determines patient reimbursement for Medicare and other episodic payors and also results in publicly reported patient outcomes and additional payment impacts related to value based purchasing
Perform Patient care primarily in the patient’s residence or skilled nursing facility (50%)
Travel to and from patient residence
Education and Formal Training
Associate Degree or Diploma, Nursing required
Professional Work Experience
~1-2 years of med-surgical, critical care or home health/hospice/infusion preferred
~ Prior experience in Home Health, Hospice or Infusion preferred
~ Prior OASIS and PDGM experience preferred for home health
Working knowledge of Medicare and Medicaid regulations, including JCAHO and DFS standards, ICD-9 Coding.
Knowledge of and appropriate application of the nursing process
Ability to assess nursing needs of acute and chronically ill patients and their families
Ability to communicate clearly with patients, families, visitors, healthcare team, physicians, administrators, leadership and others
Ability to teach patients and families in accordance with the nursing plan of care
Ability to record activities, document assessments, plan of care, interventions, evaluation and re-evaluation of patient status
Ability to use computer and learn new software programs and technology
Able to document and communicate pertinent information using computer and/or paper documentation tools
Knowledge in wound identification and treatments, infusion and other advanced nursing skills
Working knowledge of infection control procedures and safety precautions
Strong computer skills including MS Outlook, Word, Excel, preferred
Able to withstand driving long distances, stooping, bending, lifting 20 plus pounds, and climb stairs
Duke 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 essentialjob functions that require specific physical and/or mental abilities.
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