RN-Clinical Documentation/Performance Improvement Specialist
Clinical Documentation Specialist (CDS): The CD/PI Specialist uses a variety of collaborative strategies with multidisciplinary team members to ensure the level of severity of illness and service provided are accurately reflected in the medical record. Is responsible for independently planning, organizing, and performing quality review and analysis of patient care documents, providing ongoing education regarding documentation requirements and the data validation of code assignment specific to the type of care provided. Completes reviews on assigned patients and teams of patients and takes appropriate actions to make and/or communicate needed changes in care to the interdisciplinary team. Responsible for providing leadership for the medical center in the aspects of assessment, measurement, and process improvement with regards to patient care and organizational functions. The CD/PI Specialist trends data for populations and providers performance improvement actions that demonstrate improved outcomes at the service and facility levels and beyond. Leads interdisciplinary teams in the development and coordination of the medical center and service level performance improvement initiatives, especially related to quality of care and SAIL domains. Demonstrates knowledge and ability to apply principles of evidence-based practice. Is knowledgeable of utilization management processes, clinical documentation systems and requirements, current standards of care, coding and compliance guidelines, diagnostic related groupings (DRGs) and third party payment regulations. Must possess knowledge of the International Classification of Diseases 10th Revision Clinical Modification (ICD-10-CM), Current Procedural Terminology (CPT) and Diagnostic and Statistical Manual of Mental Disorders (DSM IV).
Work Schedule: typically 730 am-4 pm but may be variable with occasional extended hours or weekend work
- 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.
MSN with 2-3 years of Nursing experience
Experience with ICD10 codes/documentation requirements
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 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.
The work is sedentary. Typically, the employee may sit comfortably to perform portions of the work. However, there is daily walking, standing, and moving around patient care units .
Use of fingers
Use of both hands
Ability for rapid mental and muscular coordination simultaneously
Near vision correctable
Far vision correctable
Hearing (aide permitted)
Work closely and effectively with others, as well as, protracted or irregular hours of work
To apply for this position, you must provide a:
Detailed Resume or CV
The following documents are accepted, and will be required post interview.
VA Form 10-2850a - Application for Nurses and Nurse Anesthetists can be found at: http://www.va.gov/vaforms/search_action.asp?FormNo=2850&tkey=&Action=Search.