OUR MISSION: To fulfill President Lincoln's promise - "To care for him who shall have borne the battle and for his widow, and his orphan" - by serving and honoring the men and women who are America's Veterans. How would you like to become a part of a team providing compassionate care to Veterans?
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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
Occasional travel - You may be expected to travel for this position.