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    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.

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    • 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.
    Work Schedule: Monday-Friday 0800-1630

    Travel Required

    25% or less - You will be expected to travel for this position.

    Supervisory status


    Promotion Potential


  • Job family (Series)

    0610 Nurse

This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/532330400. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.