The Clinical Documentation Coordinator (CDC) Registered Nurse is a trained, licensed health care professional who evaluates the medical record documentation for completeness, continuation of care, & medical coding purposes. Interacts directly with providers & medical coders to ensure clinical documentation captures accurate & complete descriptors of patient illness & services/treatment rendered. Responsible for performing qualitative and quantitative review & analysis of clinical documentation.
Summary
The Clinical Documentation Coordinator (CDC) Registered Nurse is a trained, licensed health care professional who evaluates the medical record documentation for completeness, continuation of care, & medical coding purposes. Interacts directly with providers & medical coders to ensure clinical documentation captures accurate & complete descriptors of patient illness & services/treatment rendered. Responsible for performing qualitative and quantitative review & analysis of clinical documentation.
Works closely with Providers, Clinical Service Chiefs, ancillary & administrative support staff at facility to ensure all encounter submissions are successfully completed, action required cases & unsigned documents are addressed. Collaboratively works with the professional clinical staff & provides support/education on documentation issues. Assists in the development of guidelines for data compatibility, consistency, & monitoring for compliance to improve the quality for clinical, financial, & administrative data to ensure that all information is fully documented & supported. Such efforts are conducted to insure the accuracy and quality of healthcare given, billing denials, prevention against fraud & abuse to maximize the medical center's authorized reimbursement for utilization of resources provided.
Provides guidance on documentation and coding issues to coding, clinical & professional staff. Provides and assists in the performance of training, in-services and other educational activities to staff regarding diagnosis & procedure code assignment, government regulatory requirements, use of encoder software & to secure regulatory data quality goals. RN develops and conducts seminars, workshops, short courses, informational briefings, & conferences concerned with medical record documentation educational & 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 & contract staff, clinical & administrative staff, Regional Counsel, Executive Leadership, & 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, & CPT coding guidelines, & current VA, Joint Commission, & NCQA standards & guidelines.
Coordinates & assists the development of standardized, system-wide guidelines, procedures & education materials for coding & abstracting to meet the rules & regulation of governmental health programs, VA, & other external entity requirements and payers. Tracks data validation monitors & reviews reports for coding personnel education efforts, provides results.
Selective Service Registration is required for males born after 12/31/1959
You may be required to serve a probationary period
Subject to a background/security investigation
Must be proficient in written and spoken English
Selected applicants will be required to complete an online onboarding process
Must pass pre-employment physical examination
Qualifications
To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 05/16/2019. 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:
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.
Have flexibility to adjust the schedule occasionally to accommodate other schedules and/or deadlines or projects.
Demonstrate computer literacy through successful use of CPRS, VistA, and Microsoft Office functions such as Outlook, Word and Excel.
Excellent relationship skills, including a high degree of psychological sophistication and non-aggressive assertiveness.
Effectively manage assigned resources and identify creative strategies to increase efficiency within area(s) and program. Prepare reports and analyze data to assure resources are efficiently used, while providing quality care in assigned area(s).
Demonstrate team building success in areas of depth of knowledge, leadership strength, and resiliency within the team.
Ability to build effective partnerships and influence other staff across a diverse and complex organization.
Demonstrate critical thinking, influencing problem solving and analytical skills.
Demonstrate leadership qualities that inspire confidence, innovation, appropriate risk-taking, achievement of high standards, and a commitment to patient centered-care.
Possesses a high level of integrity and demonstrated commitment to working in a transparent way.
Effective consensus-builder and consummate team player with strong negotiation, persuasion and communication skills.
Highly professional and mature individual who exemplifies honesty and integrity.
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)
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 and approximately 2-3 year's of nursing practice/experience.
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:
Use and function of all normal motor and sensory anatomy for provision of patient care, reading, writing, listening, observing/seeing, heavy lifting, bending, pulling, pushing, stooping, squatting, walking, standing, use of fine motor muscles; visual and auditory acuity; emotional intelligence to respond to stressful and/or emergent situations and crises appropriately and calmly; self-care skills to maintain physical, psychological, and emotional health. Examples include: heavy lifting of 45 pounds and over, heavy carrying of 45 pounds and over, straight pulling, pushing, reaching above shoulder, use of fingers, both hands required, walking, standing, kneeling, repeated bending, ability for rapid mental and muscular coordination simultaneously, near vision correctable at 13" to 16" to Jaeger 1-4, far vision correctable in one eye to 20/20 and to 20/40 in the other.
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: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.
Additional information
Annual leave shall accrue for full-time Nurses, and Nurse Anesthetists at the rate of 8 hours for each full biweekly pay period.
This job opportunity announcement may be used to fill additional vacancies.
It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment.
This position is in the Excepted Service and does not confer competitive status.
VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority.
Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.
If you are unable to apply online view the following link for information regarding an Alternate Application.
A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new windowLearn more about federal benefits.
Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.
How you will be evaluated
You will be evaluated for this job based on how well you meet the qualifications above.
IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, résumé, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment.
NOTE: Candidate's education and length of nursing practice (experience) will be considered by a Nurse Professional Standards Board in determining the grade and salary of the applicant selected. The recommended salary may be at any point in the range listed for this vacancy.
Experience as an RN will be evaluated to determine if the experience is of an acceptable level of quality with regard to the following four dimensions of nursing: Practice, Professional Development, Collaboration and Scientific Inquiry. Each dimension of practice has criteria that demonstrate essential core competencies for VHA Nursing Personnel.
Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.
A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new windowLearn more about federal benefits.
Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.
Application must be within the past year. Otherwise you will be made ineligible.
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 (current/former Federal employees), etc.
Cover Letter
DD-214
OF-306
VA Form 10-2850a RN application
Other Veterans Document
Resume
SF-15
SF-50
Transcript
If you are relying on your education to meet qualification requirements:
Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.
All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (ET) on 05/16/2019 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/10491327.
To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire.
Click Submit My Answers to submit your application package.
NOTE: It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date.
To verify your application is complete, log into your USA JOBS account, https://my.usajobs.gov/Account/Login, select the Application Status link and then select the more information link for this position. The Details page will display the status of your application, the documentation received and processed, and any correspondence the agency has sent related to this application. Your uploaded documents may take several hours to clear the virus scan process. To return to an incomplete application, log into your USA JOBS account and click Update Application in the vacancy announcement. You must re-select your resume and/or other documents from your USA JOBS account or your application will be incomplete.
NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). HCP are individuals who, during the influenza season, work in VHA locations where patients receive care or who come into contact with VA patients as part of their duties. VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased facilities. HCP include all VA licensed and unlicensed, clinical and administrative, paid and unpaid, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, students, researchers, volunteers, and trainees who work at these facilities. HCPs that are unable to receive or otherwise decline a flu shot will be expected to wear a face mask throughout the influenza season.
VA Northern California Health Care System
10535 Hospital Way
Mather, CA 95655
US
Next steps
Once your online application is submitted you will receive a confirmation notification by email. After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met. After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.
You may check the status of your application at any time by logging into your USA Jobs account and clicking on Applications. Information regarding your application status can be found in the USAJobs Help Center.
The Federal hiring process is set up to be fair and transparent. Please read the following guidance.
Application must be within the past year. Otherwise you will be made ineligible.
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 (current/former Federal employees), etc.
Cover Letter
DD-214
OF-306
VA Form 10-2850a RN application
Other Veterans Document
Resume
SF-15
SF-50
Transcript
If you are relying on your education to meet qualification requirements:
Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.
All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (ET) on 05/16/2019 to receive consideration. To preview the questionnaire click https://apply.usastaffing.gov/ViewQuestionnaire/10491327.
To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire.
Click Submit My Answers to submit your application package.
NOTE: It is your responsibility to ensure your responses and appropriate documentation is submitted prior to the closing date.
To verify your application is complete, log into your USA JOBS account, https://my.usajobs.gov/Account/Login, select the Application Status link and then select the more information link for this position. The Details page will display the status of your application, the documentation received and processed, and any correspondence the agency has sent related to this application. Your uploaded documents may take several hours to clear the virus scan process. To return to an incomplete application, log into your USA JOBS account and click Update Application in the vacancy announcement. You must re-select your resume and/or other documents from your USA JOBS account or your application will be incomplete.
NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). HCP are individuals who, during the influenza season, work in VHA locations where patients receive care or who come into contact with VA patients as part of their duties. VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased facilities. HCP include all VA licensed and unlicensed, clinical and administrative, paid and unpaid, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, students, researchers, volunteers, and trainees who work at these facilities. HCPs that are unable to receive or otherwise decline a flu shot will be expected to wear a face mask throughout the influenza season.
VA Northern California Health Care System
10535 Hospital Way
Mather, CA 95655
US
Next steps
Once your online application is submitted you will receive a confirmation notification by email. After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met. After the review is complete, a referral certificate(s) is issued and applicants will be notified of their status by email. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.
You may check the status of your application at any time by logging into your USA Jobs account and clicking on Applications. Information regarding your application status can be found in the USAJobs Help Center.
Fair and transparent
The Federal hiring process is set up to be fair and transparent. Please read the following guidance.
