The Clinical Documentation specialist will provide active concurrent/retrospective review, provide feedback, and educate clinical care providers to improve the documentation of all conditions, treatments, and care plans within the health record to accurately reflect the condition of the patient and promote patient care. In addition, documentation should reflect documentation associated with MS-DRG assignment, case mix index, severity of illness, risk of mortality, physician profiling, hospital profiling, and reimbursement rules.
As a Clinical Documentation Specialist, incumbent is responsible for providing ongoing education to our providers and coding team members by conducting initial and extended-stay concurrent review on selected admissions and document findings identifying missed opportunities and clinical documentation improvements which will both enhance the quality of the health record documentation, maximize VERA and 3rd Party Collections. Incumbent identifies co-morbidities and complications and documents appropriately. Incumbent queries the medical staff and other clinical caregivers as necessary via written/verbal communication to obtain accurate and complete documentation. Provides ongoing education to physicians and other clinical care providers, related to documentation, changes in coding, compliance issues, profiling concerns, and reimbursement changes according to VA regulations and policies.
Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting, and use of an electronic medical record.
Advise and assist the Health Information Management section in the identification of training, in-services or educational needs of personnel. In addition, Clinical Documentation Specialist will present educational resources to the health information management staff and the professional staff as needed or provide goals as requested.
Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines.
Conducts re-reviews of codes abstracted for patient encounters identified by the VISN VERA Committee to determine if based on the documentation the specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA program.
For all assignments above the journey level, the higher-level duties must consist of significant scope, complexity (difficulty), range of variety, and be performed by the incumbent at least 25% of the time.
Performs other related duties as assigned.
Work Schedule: Full time 7:00am to 3:30pm (Can be negotiated at time of interview)
Compressed/Flexible: Not Authorized
Virtual: This is a virtual position.
Functional Statement #: F 1480
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
PCS Appraised Value Offer (AVO): Not Authorized
Starting at $67,743 Per Year (GS 9)
