The Clinical Documentation Improvement Educator/Nurse Advisor is responsible for providing the clinical expertise as part of the Medical Center's Clinical Documentation Improvement program. He/she possesses up-to-date clinical knowledge to review medical records, identify opportunities for improved documentation, and has knowledge of utilization management processes, clinical documentation requirements, current standards of care, coding and compliance guidelines.

Duties

The Clinical Documentation Improvement Educator/Nurse Advisor is accountable for utilizing a variety of collaborative strategies with physicians, Clinical Documentation Improvement Specialists, 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. S/He assists with education of CDIS staff on identification of clinical indicators for disease processes, assists CDI and Coding staff develop clinically appropriate and compliant facility provider queries to further clarify documentation, and assists with the analysis of coded data used to determine, measure, and report severity and risk adjusted outcomes and cost for various metrics. The incumbent provides leadership for and participates in performance improvement/education activities. Assists in determining educational needs of medical staff related to clinical documentation improvement, collaborates with medical staff, nursing staff, CPAC, and HIM leadership to promote learning experiences for all clinical personnel to achieve quality patient documentation of care. He/she uses performance improvement methodologies and education strategies to develop formal training improvement programs for the medical/hospital staff concerning clinical documentation opportunities, coding and reimbursement issues and provides ongoing updates as regulations change. He/she must possess the ability to interact with a wide variety of employees and to work independently in accomplishing assignments and program goals. The Clinical Documentation Improvement Educator/Nurse Advisor assists the Revenue Office in program direction, planning, and implementation of a fully integrated Clinical Documentation Improvement program. Central Texas VHCS is in the process of making a cultural change, shifting from a disease-focused approach to a health and wellbeing approach, in order to implement the Whole Health System of Care. This is a VA-wide initiative to provide a comprehensive and systematic approach to improve healthcare delivery at all stages of Veteran care. This entails moving from an episodic, "siloed" approach to an interdisciplinary, holistic approach, emphasizing self-care in the larger context of well-being. All staff in this facility will be part of this process, shifting the focus from the question, "What's the matter with you?" to the question, "What matters to you, and how can we help you live your best life?" This strategy also involves integrating a full range of conventional approaches with Complementary and Integrative Health (CIH) approaches in order to optimize lifelong health and well-being, as defined by the Veteran, rather than narrowly focusing on disease management. VA offers a comprehensive total rewards package: VA Nurse Total Rewards Pay: Competitive salary, regular salary increases, potential for performance awards Paid Time Off: 50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 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 Work Schedule: M-F 0730-1600 Telework: Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required

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. HPTs who are on track to graduate/complete the requirements should respond as if they have met the requirements. Provide details in the narrative sections of the assessment. 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: Evidence of Belt/Systems Redesign training/experience/certification SNT/GNT/RNTTP completion

Education

The Associate Degree Nursing (ADN), Bachelor of Science degree in Nursing (BSN), or Master of Science degree in Nursing (MSN) must be fully accredited by the Accreditation Commission for Education in Nursing (ACEN) or the Commission On Collegiate Nursing Education (CCNE). Verification of accreditation may be obtained from http://www.acenursing.us/accreditedprograms/programsearch.htm or https://directory.ccnecommunity.org/reports/accprog.asp

• If your school has changed names, or is no longer in existence, you must provide this information in your application.
• If your school was accredited by ACEN or CCNE at the time of graduation, but is no longer listed on the websites, you must provide documentation of accreditation with your application packet.

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.

IMPORTANT: A transcript must be submitted with your application if you are basing all or part of your qualifications on education.

Contacts

• Address VA Central Texas Health Care System 1901 Veterans Memorial Drive Temple, TX 76504 US
• Name: VISN 17 SSU USAS Group
• Email: [email protected]