RN Clinical Documentation Coordinator
Major duties include, but may not be limited to:
- 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 insure 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 efficiently and effectively perform the clinical review 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, HIMS and committees as needed. Tracks all pending action items for appropriate follow-up.
- Performs fact-finding as needed to research coding compliance issues.
- Performs quantitative and qualitative review and analysis of health records and encounter information of outpatients both concurrently and retrospectively, to ensure documentation in both is accurate, consistent, complete and assigned codes can be supported by the documentation.
- Collaborates with clinical staff to provide education, feedback, and assistance regarding documentation of medical necessity, insurance review criteria, and special compensation issues and documents the results of the review in VISTA and coordinates continuity of care with facility revenue staff as needed.
Financial Disclosure Report: Not required 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.
- Graduate of a school of professional nursing approved by the appropriate State-accrediting agency and accredited 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). 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.
- BSN and/or Master's degree from an accredited school of nursing recognized by the VA (Commission on Collegiate Nursing Education (CCNE) or The Accreditation Commission for Education in Nursing (ACEN).
- Certification as a medical coder or Clinical Documentation Improvement Specialist.
- Experience and knowledge of regulations that define healthcare documentation requirements, including the Joint commission, CMS, and VA guidelines;
- Experience and knowledge of coding rules and requirements to include clinical classification systems (such as current versions of ICD and CPT), complication or comorbidity/major complication or comorbidity (CC/MCC), Medicare Severity Diagnosis Related group (MS_DRG) structure, and Present on Admission (POA) indicators;
- Experience and knowledge of severity of illness and risk of mortality indicators
- Experience and knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development and documentation improvement. The training sessions may be technical in nature or may focus on teaching techniques for the improvement of clinical documentation issues.
- Current proficiency in Basic Life Support (BLS) through the American Heart Association (Required prior to assuming clinical duties and must remain current -VHA Directive 11-77)
- 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 year's of nursing practice/experience; OR a Master's degree in nursing or related field with a BSN and approximately 1-2 year's 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 year's of nursing practice/experience; OR a Doctoral degree.
- 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.
To apply for this position, you must provide a complete Application Package which includes:
- VA FORM 10-2850a
The following documents are accepted, and may be required if applicable to your eligibility and/or qualifications for this position. Please use this checklist to ensure you have included all documents required for your application, such as a copy of your transcript (if using education to qualify), etc.
- VA FORM 10-2850a