RN - CLINICAL DOCUMENTATION IMPROVEMENT EDUCATOR

Location
San Antonio, TX
Salary
Competitive
Posted
Jul 16, 2019
Closes
Aug 15, 2019
Specialty
Education, Other
Contract Type
Permanent
Hours
Full Time
The RN reports to the Nurse Manager of Inpatient Flow. The RN serves as the clinical liaison between Health Information Management, Utilization Management, and the Medical Center clinical staff. He/she possesses up-to-date clinical knowledge to efficiently and concurrently review medical records, in conjunction with Utilization Management, to identify opportunities for improved documentation to accurately reflect the specific condition of the Veteran. The RN has knowledge of utilization management processes and current standards of care. The RN is accountable for utilizing a variety of collaborative strategies with physicians, mid-level providers, and other members of the interdisciplinary team, to ensure the severity of illness and level of service provided are accurately reflected in the medical record for the delivery of quality patient care services. The incumbent provides leadership for and participates in performance improvement activities. He/she uses performance improvement methodologies and education strategies to develop formal training improvement programs for the clinical staff concerning medical documentation opportunities. The RN provides leadership and assumes continuous responsibility for the development, implementation, coordination, maintenance and evaluation of the medical center's medical documentation improvement program.

Work Schedule: Rotating shifts to meet the needs of the facility
Financial Disclosure Report: Not required
This is a Bargaining Unit Position.

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.

Preferred Experience: Clinical Documentation Improvement experience, recent nursing experience in Medical/Surgical, outpatient, and/or ICU, recent Utilization Management, Quality Management, process improvement, coding, process improvement, or utilization review/case management in an
acute care facility, Certification for Clinical Documentation Specialist (CCDS).

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.

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.

English Proficiency: Must be proficient in spoken and written English as required by 38 U.S.C. 7402(d) and 7407(d).

Physical Requirements: Moderate Lifting (15-44 lbs); Moderate Carrying (15-44 lbs); Straight Pulling (1 hour); Pushing (1-3 hours); Reaching above shoulder; Use of fingers; Both hands required; Walking (4 hours); Standing (2-7 hours); Kneeling (2 hours); Repeated bending (2 hours); Climbing, use of legs and arms; Both legs required; Ability for rapid mental and muscular coordination simultaneously; Near vision correctable at 13" to 16" to Jaeger 1 to 4; Specific visual requirement: 20/40 DVA, corrected; Both eyes required; Ability to distinguish basic colors; Hearing (aid permitted); Sitting (8 hours); Simple Grasping (2-4 hours); Fine Manipulation (including keyboarding 4-6 hours); Twisting (2 hours); Mental and Emotional Stability.None

To apply for this position, you must provide a complete Application Package which includes:
  • Resume

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.

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), SF-50's, etc.
  • Cover Letter
  • DD-214
  • OF-306
  • 10-2850a Application for Nurses and Nurse Anesthetists
  • Other Veterans Document
  • Resume
  • SF-15
  • SF-50
  • Transcript

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