The RN Clinical Documentation Specialist (CDS) is responsible for providing the clinical expertise and leadership for the implementation of the Medical Center's Clinical Documentation Improvement Program. The incumbent possesses up -to-date clinical knowledge to efficiently and concurrently review medical records and identify opportunities for improved documentation.

Duties

Utilizes a variety of collaborative strategies with physicians, mid-level providers and other members of the interdisciplinary team, Medical Care Cost Recovery (MCCR) and Health Information Management (HIM) staff to ensure the severity of illness and level of service provided are accurately reflected in the medical record, maximizing third party collections and delivering quality patient care services. Uses performance improvement methodologies and education strategies to determine the educational needs of clinical and non- clinical staff related to clinical documentation improvement, collaborates with medical and non- medical staff, nursing staff, CPAC/MACPAC, HIMS and Coding to promote learning experiences for all personnel regarding the achievement of quality patient documentation of care. Demonstrates knowledge of complex automated data processing systems and their application for communication and data management (e.g., Claims Tracking software, VISTA, CPRS, VSSC, VHA Intranet, Microsoft Word, Excel and Outlook, PowerPoint). Possesses an expert understanding of clinical treatment modalities, organization and administration of the VA healthcare delivery systems, educational principles, clinical information systems, accreditation and regulatory standards, and program development. Determines the most appropriate use of expertise in systems issues requiring intervention and quality and performance measures. Initiates and maintains databases, prepares, reports, and works collaboratively with others to assess variances and project needs to improve the work force and resource utilization. Work Schedule: 8:00 am - 4:30 pm, Monday - Friday Financial Discloser Report: Not required Recruitment Incentive: No

Requirements

Qualifications

Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met. 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: Acute Care experience, extensive knowledge of CPRS, and clinical documentation reviews. 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: This position requires visual acuity, keen hearing, clear distinctive speech, and manual dexterity. This position may require potentially long periods of continued walking, standing, stooping, sitting, bending, pulling, and pushing. The incumbent may occasionally be exposed to infected patients and contaminated materials and may required to don protective clothing in insolation situations or operative/invasive procedures. The incumbent may occasionally be exposed to patients who are combative secondary to delirium, dementia, or psychiatric disorders.

Education

IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on 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 Carl Vinson VA Medical Center 1826 Veterans Boulevard Dublin, GA 31021 US
• Name: Staci Benson
• Phone: 4782721210
• Email: [email protected]