Cdi Specialist

**Duties**:
Duties of the position include but are not limited to:

- Responsible for reviewing the overall quality and completeness of clinical documentation. Inpatient CDIS focuses on the concurrent review of patient records with an emphasis on improving documentation while the patient is still in-house while outpatient CDIS focuses on improving clinical documentation of outpatient encounters through retrospective, ideally prior to coding and billing, review of outpatient encounters and extensive provider education.
- Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure clinical documentation supports proper code selection.
- Reviews clinical documentation and provides education to clinical staff on both inpatient and outpatient episodes of care including admissions and discharges, observation, emergency department/urgent care, and clinic visits
- Prepares and conducts provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding.
- Provides education to providers on the need for accurate and complete documentation in the health record, appropriate code selection of Evaluation and Management (E/M), Current Procedural Terminology (CPT) and ICD-10 diagnosis codes, and ensuring documentation supports the codes selected to the highest degree of specificity.
- Adheres to accepted coding practices, guidelines and conventions when verifying the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding.
- Reviews VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinates provider documentation education with the VERA coordinator. Ensures documentation supports codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.
- Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.
- Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. Ensures provider documentation is complete and supports the diagnoses and procedures coded. Directly consults with the professional staff for clarification of conflicting or ambiguous clinical documentation. Reports incorrect documentation or codes in the electronic patient health record.
- Expertly searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record. Queries the medical staff and other clinical caregivers as necessary to obtain accurate and complete documentation.
- Develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM) staff.

**Work Schedule**: To Be Determined, at the time of selection.

**Compressed/Flexible**:Not available.

**Telework**: Available.

**Virtual**: This is a virtual position.

**Functional Statement #**: 0000000

**Relocation/Recruitment Incentives**: Not authorized.

**Permanent Change of Station (PCS)**:Not authorized.

**Fi**nancial Disclosure Report**: Not required

**Requirements**:
**Conditions of Employment**:

- Selective Service Registration is required for males born after 12/31/1959.
- Must be proficient in written and spoken English.
- You may be required to serve a probationary period.
- Subject to background/security investigation.
- Selected applicants will be required to complete an online onboarding process.
- Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
- Participation in the Coronavirus Disease 2019 (COVID-19) vaccination program is a requirement for all Veterans Health Administration Health Care Personnel (HCP) - See "Additional Information" below for details.

**Qualifications**:

- All requirements must be met by the close of the announcement.
- **Citizenship.** Citizen o