The incumbent functions in support of the Clinical Documentation Improvement (CDI) Program through ongoing review and demonstration of expert clinical knowledge in evaluation of programs and services. The position initiates and maintains databases, prepares reports, and works collaboratively to assess and actively participate in quality improvement processes and initiatives.
The incumbent educates staff at all levels and works collaboratively with the Health Information Management (HIM) Medical Records Technician (MRT) CDI coding staff on facility clinical documentation improvement objectives. Acts as a liaison between the MRT-CDI coding staff and the clinical staff to facilitate and support the objectives of accurate and timely documentation in support of coding, Medicare Severity-Diagnosis Related Group (MS-DRG) assignment, and representation of severity, acuity, and risk of mortality.
The incumbent collaborates and communicates with designated staff to optimize accuracy of information in support of accurate data capture for the purpose of revenue. Collaborates with facility staff to identify patterns in documentation, deficiencies in documentation, lack of specificity, or medical necessity for services rendered. Collaboration should include corrective actions and education of providers and support staff.
The incumbent serves as the only subject matter expert for the VERA model within the medical center. The incumbent independently analyzes the varying and complex data streams that feed the VERA model in real time and assures that correct data is being used at the right time, that the data is accurate and is the best data to be used given a pool of other sources. If the incumbent finds that there is a deficiency in the data or data quality, the incumbent will work with stakeholders throughout the organization to correct inaccuracies and ensure processes are in place to avoid future discrepancies. The incumbent serves as an advisor to the highest of leadership at the medical center, as well as other clinical staff and Health Information Management. Through expert understanding of the VERA model, the incumbent will ensure that the medical center is receiving the full funding and resource allocation possible.
The incumbent demonstrates knowledge of MIS programs sufficient to evaluate accomplishment of overall programs, identify existing or potential problem areas, and recommend corrective action of preventive measures.
United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
Graduate of a school of professional nursing approved by the appropriate State-accrediting agency and accredited by one of the following accrediting bodies at the time the program was completed by the applicant: The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE). In cases of graduates of foreign schools of professional nursing, possession of current, full, active and unrestricted registration will meet the requirement of graduation from an approved school of professional nursing. OR The completion of coursework equivalent to a nursing degree in a MSN Bridge Program that qualifies for professional nursing registration constitutes the completion of an approved course of study of professional nursing. Students should submit the certificate of professional nursing to sit for the NCLEX to the VA along with a copy of the MSN transcript. (Reference VA Handbook 5005, Appendix G6) OR In cases of graduates of foreign schools of professional nursing, possession of a current, full, active and unrestricted registration will meet the requirement for graduation from an approved school of professional nursing.
Current, full, active, and unrestricted registration as a graduate professional nurse in a State, Territory or Commonwealth (i.e., Puerto Rico) of the United States, or the District of Columbia.
BSN preferred. 2-5 years of clinical experience preferred.
Knowledge of medical record documentation concepts and guidelines
Knowledge of clinical classification systems (ICD, CPT), (CC/MCC), MS-DRG structure, and POA indicators.
Knowledge of severity of illness and risk of mortality indicators
Knowledge of current trends in clinical and administrative practice, computer technology, and health care.
Skill in compiling and analyzing data.
Ability to teach others.
Ability to plan, coordinate, and implement projects.
Skill in applying clinical knowledge, analytical, and problem-solving techniques in the area of informatics and clinical documentation.
Excellent organizational and communication skills.
Certification through the Association of Clinical Documentation Improvement Specialists (Certified Clinical Documentation Specialist-CCDS) or the American Health Information Management Association (Certified Documentation Improvement Practitioner-CDIP) is preferred.
Grade Determinations: The following criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade:
Nurse I Level I - An Associate Degree (ADN) or Diploma in Nursing, with no additional nursing practice/experience required.
Nurse I Level II - An ADN or Diploma in Nursing and approximately 1 year of nursing practice/experience; OR an ADN or Diploma in Nursing and a bachelor's degree in a related field with no additional nursing practice/experience; OR a Bachelor's of Science in Nursing (BSN) with no additional nursing practice/experience.
Nurse I Level III - An ADN or Diploma in Nursing and approximately 2-3 years of nursing practice/experience; OR an ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 1-2 years of nursing practice/experience; OR a BSN with approximately 1-2 years of nursing practice/experience; OR a Master's degree in nursing (MSN) or related field with a BSN and no additional nursing practice/experience.
Nurse II - A BSN with approximately 2-3 years of nursing practice/experience; OR ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 2-3 year's of nursing practice/experience; OR a Master's degree in nursing or related field with a BSN and approximately 1-2 year's of nursing practice/experience; OR a Doctoral degree in nursing or meets basic requirements for appointment and has doctoral degree in a related field with no additional nursing practice/experience required.
Nurse III - Master's degree in nursing or related field with BSN and approximately 2-3 year's of nursing practice/experience; OR a Doctoral degree.
Reference: VA Regulations, specifically VA Handbook 5005, Part II, Appendix G-6 Nurse Qualification Standard. This can be found in the local Human Resources Office.
To apply for this position, you must provide a complete Application Package which includes:
VA Form 10-2850a - Application for Nurses and Nurse Anesthetists can be found at: http://www.va.gov/vaforms/search_action.asp?FormNo=2850&tkey=&Action=Search.
The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this checklist to ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), SF-50's, etc.
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