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We need someone with the following qualifications to contact us regarding a position immediately:

Clinical Documentation Specialist

  1. Bachelor's degree in health information management, nursing or equivalent
  2. currently licensed as a Registered Nurse or other relevant LIP (licensed independent provider)
  3. Certified Clinical Documentation Specialist (CCDS) and/or Clinical Documentation Improvement Practitioner (CDIP)
  4. The Clinical Documentation Specialist must also have the following Competencies and Skills:
    • Knowledge of coding and documentation concepts, guidelines and clinical terminology
    • Ability to interpret and analyze all information in a patient’s health record including laboratory and other test results to identify opportunities for more precise and/or complete documentation in the health record
    • Clinical knowledge (anatomy and physiology, pathophysiology, and pharmacology)
    • Ability to establish and maintain strong verbal and written communication with providers
    • Knowledge of healthcare regulations that define healthcare documentation requirements, including, The Joint Commission, CMS and VHA guidelines
    • 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), MS-DRG structure, and POA indicators
    • Knowledge of severity of illness and risk of mortality indicators
    • Applied knowledge of documentation impact on reimbursement to include VERA funding through the Allocation Resource Center (ARC) and third party payer requirements
    • Knowledge of VHA Handbook 1907.01, Health Information Management and Health Records, VHA Handbook 1907.03, HIM Clinical Coding Program Procedures, VHA Coding Guidelines, and Medical Staff Bylaws