The Clinical Documentation Coordinator Registered Nurse is a trained, licensed health care professional who evaluates the medical record documentation for completeness, continuation of care, and medical coding purposes. Interacts directly with providers and medical coders to ensure clinical documentation captures accurate and complete descriptors of patient illness and services/treatment rendered. Responsible for performing qualitative and quantitative review and analysis of documentation.

Duties

- Works closely with Providers, Clinical Service Chiefs, ancillary and administrative support staff at facility to ensure all encounter submissions are successfully completed, action required cases and unsigned documents are addressed. Collaboratively works with the professional clinical staff and provides support and education on documentation issues. Assists in the development of guidelines for data compatibility, consistency, and monitoring for compliance to improve the quality for clinical, financial, and administrative data to ensure that all information is fully documented and supported. Such efforts are conducted to ensure the accuracy and quality of healthcare given, billing denials, prevention against fraud and abuse to maximize the medical center's authorized reimbursement for utilization of resources provided. - Provides guidance on documentation and coding issues to coding, clinical and professional staff. Provides and assists in the performance of training, in-services and other educational activities to staff regarding diagnosis and procedure code assignment, government regulatory requirements, use of encoder software and to secure regulatory data quality goals. Incumbent develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with medical record documentation educational and functional training requirements to ensure program objectives are met for the facility. - Maintains collaborative working relationships with the Consolidated Patient Account Center (CPAC), Health Information Management staff and contract staff, clinical and administrative staff, Regional Counsel, Executive Leadership, and other key stakeholders in the Medical Center. Participates in external reviews of the organization surveys (The Joint Commission, OIG/CAP, GAO) as directed by Medical Center executive leadership. - Maintains current knowledge of the VISTA abstracting systems, encoder software, VISN/VA, ICD-10-CM, and CPT coding guidelines, and current VA, Joint Commission, and NCQA standards and guidelines. - Coordinates and assists the development of standardized, system-wide guidelines, procedures and education materials for coding and abstracting to meet the rules and regulation of governmental health programs, VA, and other external entity requirements and payers. Tracks data validation monitors and reviews reports for coding personnel education efforts, provides results. - Monitoring day-to-day review activity for productivity and quality of documentation and coding. - Performs concurrent reviews to validate the medical documentation. Will query providers when clarification or additional documentation is needed. - Uses advanced clinical knowledge and communication skills to perform the clinical review efficiently and effectively in CPRS and provides technical staff support for the administration of the medical center's Health Information Management program. This position will develop new or improved solutions to complex technical problems using process improvement abilities. - Reviews reports of unsigned progress note cases, makes appropriate adjustments, and provides technical advice and support regarding the repair of discrepancies in the documentation or the processing of billable encounters. - Assists the health care team in coding with the highest degree of accuracy. - Completes a monthly Reasons Not Billable Review and monthly Coding Audits of provider documentation for coding accuracy and documentation specificity. These findings are reported to the Coding Supervisor and Compliance Committee. - Develops and coordinates internal monitoring to oversee quality and education with documentation, HIMS, coding and billing issues. Maintains reports of monitoring activities, as well as follow-up reports when necessary. Gives timely feedback to providers, staff and supervisors concerning audit findings. Develops education sessions and procedures based on audit findings. Generate, analyze, validate, and present reports to the Chief of HIMS and committees as needed. Tracks all pending action items for appropriate follow-up. 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: Monday to Friday, 0800-1630 Telework: AD-HOC 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. 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. 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: - Involves considerable amount of standing, walking, stooping, bending, reaching, lifting, and turning. - Requires carrying or lifting of objects weighing up to 50 lbs., but occasionally may require work that involves pushing or lifting more than 50 pounds and going up and down flights of stairs. - Requires the ability to frequently respond to multiple demands and priorities. - Has potential for exposure to infectious diseases, hazardous waste and chemicals. - Emotional and mental stability - ability to effectively perform the essential functions of the position and respond appropriately in emergency situations.

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: https://sites.ed.gov/international/recognition-of-foreign-qualifications/.

Contacts

• Address VA Northern California Health Care System 10535 Hospital Way Mather, CA 95655 US
• Name: Nina Nguyen
• Phone: 916-843-6932
• Email: [email protected]