The Clinical Documentation Integrity Advisor understands a wide range of specialized disciplines, including education in anatomy and physiology, pathophysiology, and pharmacology; knowledge of medical coding guidelines, CMS, and private payer regulations related to the Inpatient Prospective Payment System; ability to analyze and interpret medical record documentation and formulate physician queries; and an ability to benchmark and analyze clinical documentation program performance.

Duties

Major duties include but are not limited to: Responsible for comprehensive coding knowledge and experience in DRGs and ICD-10. Utilizes collaborative strategies to ensure that severity of illness and level of care are accurately reflected in the health records to optimize third party collections, VERA funding and delivery of quality patient care. Collaborates with others (Nursing, Providers, HIM, CDI, etc.) to implement changes to support improved clinical documentation. Completes assessments and/or reassessment via medical chart review, telephone conferencing and/or face-to-face contact with a primary overall goal of achieving the most complete and accurate medical record for the veteran. Collaborates with leadership team and providers to establish long and short-term goals for the CDI Team. Assists in determining educational needs of medical staff related to clinical documentation improvement. Collaborates with nursing staff, CPAC and HIM leadership to promote learning experiences for all clinical personnel to achieve quality patient documentation of care. Participates in initiating, implementing, and coordinating clinical documentation improvement programs that are cost- effective and developed to meet the best possible outcome. Collect, analyze, interpret, and prepare data for reports and presentations. Communicates effectively both orally and in writing with professional, administrative, and technical staff within the Medical Center, VHA, and professional organizations. Participates in and may assume leadership role in providing direct support for the development, coordination, maintenance and operation of the Clinical Documentation Integrity program at the facility level. Recognizes and supports Suicide Prevention initiatives. Compliance with various Isolation Precautions and Infection Control Guidelines. Maintains prevention & management of disruptive behavior skills, can be trained upon hire. Participation in High Reliability Organization (HRO) & professional governance initiatives. Promotes evidence-based best practices and nurse sensitive indicators (including but not limited to Falls Prevention, Hospital Associated Infection Prevention, Medication error prevention, Safe Patient Handling, and Skin Safety). Work Schedule: Monday-Friday, 7:30am-4:00pm Telework: VA supports the use of telework as a way to help attract and retain talented individuals in public service, increase worker productivity, and better prepare the agency to operate during emergencies. This position may be authorized for telework. Telework eligibility will be discussed during the interview process. Virtual: This is not a virtual position. Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required

Requirements

Qualifications

Basic requirements must be met by the time of application. Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. English Language Proficiency. In accordance with 38 U.S.C. 7402(d), no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English. Graduate of a school of professional nursing approved 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). The approving official may authorize a waiver of the requirement for ACEN or CCNE accreditation of any degree in nursing provided the college or university has regional accreditation from an accrediting body recognized by the Department of Education at the time of the candidate's graduation and the composite qualifications of the applicant warrant such consideration. 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. Preferred Experience: Bachelor's Degree in Nursing (BSN), or Master's Degree in Nursing (MSN). 3-5 years of recent nursing experience. Certified Clinical Documentation Specialist (CCDS). 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 years of nursing practice/experience; OR a Master's degree in nursing or related field with a BSN and approximately 1-2 years 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 years of nursing practice/experience; OR a Doctoral degree and approximately 2-3 years of nursing practice/experience. Note regarding MSN degrees: If your MSN was obtained via a Bridge Program that qualifies for professional nursing registration, a BSN is not required. 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. Physical Requirements: You will be asked to participate in a pre-employment examination or evaluation as part of the pre-employment process for this position. Questions about physical demands or environmental factors may be addressed at the time of examination.

Education

Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.

Contacts

• Address Minneapolis VA Medical Center One Veterans Drive Minneapolis, MN 55417 US
• Name: Clarissa Baccam
• Phone: 515-699-5693
• Email: [email protected]