This RN is responsible providing the clinical expertise and leadership for the implementation of the Medical Center's Clinical Documentation Improvement Specialist program. Duties include but not limited to: Review medical records on a daily basis (concurrent for inpatient; retrospectively for outpatient) to identify opportunities to clarify missing or incomplete documentation. Perform provider queries in order to clarify missing/incomplete documentation to ensure the documentation accurately reflects the severity of the condition and acuity/risk associated with the care provided. Follow-up on queries to ensure they have been addressed by the provider and appropriately documented. Collaborate with providers, coders, HIMS specialists, and other healthcare team members to facilitate comprehensive health record documentation that reflects clinical treatment, decisions, diagnoses, and interventions. Develop and provider education related to clinical documentation issues within the organization and promote complete and accurate clinical documentation. Educate providers about identification of disease processes that reflect SOI, complexity, and acuity in order to facilitate accurate application of code sets. Act as a clinical consultant to coding/HIMS professionals when additional information or documentation is needed to assign the correct code. Collaborate with HIMS and physician advisors to review individual cases to ensure accuracy of documentation and coded data. Gather and analyze information pertinent to documentation findings and outcomes and use this information to develop action plans for process improvements. Identify patterns, trends, variances and opportunities to improve documentation review processes. Act as a consultant to providers seeking feedback, education, and clarification in the clinical documentation improvement process. Work Schedule: Mon-Fri, 8:00am to 4:30pm Financial Disclosure Report: Not required Pay: Competitive salary, regular salary increases. Paid Time Off: Annual leave at the rate of eight (8) hours per biweekly pay period; Sick leave at the rate of four (4) hours per biweekly pay period; 10 paid Federal holidays per year. Retirement: Traditional federal pension (5 years' vesting) and federal 401K with up to 5% in contributions by VA. Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement). Licensure: 1 full and unrestricted license from any US State or territory. Recruitment Incentive/Relocation Incentive is not authorized for this position. Add EDRP and/or PCS statements, if applicable.
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.