John J Pershing VA Medical Center

Role Description Responsible for reviewing the overall quality and completeness of clinical documentation. Inpatient CDI focuses on the concurrent review of patient records with an emphasis on improving documentation while the patient is still in-house while outpatient CDI focuses on improving clinical staff documentation of outpatient encounters. - Facilitating improved overall quality, education, and completeness and accuracy of medical record documentation. - Promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers, HIM coding staff, and other associated staff. - Developing and/or updating medical center policy memoranda pertaining to documentation improvement. - Serving as a technical expert in health record content and documentation requirements. - Performing reviews of health record documentation; developing criteria, collecting data, graphing and analyzing results, creating reports, and communicating with appropriate leadership and groups. - Obtaining appropriate corrective action plans from responsible clinical services directors when necessary. - Recommending improvements or changes in documentation as deemed necessary. - Adhering to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policy, and medical-legal requirements. - Developing and implementing active training/education programs for all providers to ensure the CDIS program objectives are met. - Applying comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures, and the principles and practices of health services. - Selecting and assigning codes from the current version of several coding systems including ICD, CPT, and HCPCS. - Adhering to accepted coding practices, guidelines, and conventions. - Monitoring ever-changing regulatory and policy requirements affecting coded information. - Assisting facility staff with documentation requirements to accurately reflect patient care provided. - Providing technical support in areas such as regulations and policy, coding requirements, resident supervision, and reimbursement. - Ensuring provider documentation is complete and supports the diagnoses and procedures coded. - Directly consulting with professional staff for clarification of conflicting or ambiguous clinical data. - Reporting incorrect documentation or codes in the electronic patient health record. - Using a variety of window-based applications in day-to-day activities, such as Outlook, Excel, Word, and Access. - Ensuring current versions of all software applications are loaded and functional after updates or changes. Requirements - Work Schedule: Monday-Friday 8:00am - 4:30pm - Paid Time Off: 37-50 days of annual paid time off per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year). - Selected applicants may qualify for credit toward annual leave accrual based on prior work experience or military service experience. - Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child. - Child Care Subsidy: After 60 days of employment, full-time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66. - Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions by VA. - Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement). - Remote: Yes - This position is designated as remote. The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required. The selectees must live within 50 miles of a VA Medical Center. Qualifications - United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. - Experience: One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records. - Education: An associate's degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management. - Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding. - Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. - Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either Apprentice/Associate Level Certification through AHIMA or AAPC, Mastery Level Certification through AHIMA or AAPC, or Clinical Documentation Improvement Certification through AHIMA or ACDIS. Grade Determinations - MRT (CDIS - Inpatient/Outpatient), GS-9: One year of creditable experience equivalent to the GS-8 of a MRT (Coder-inpatient/outpatient). - An associate's degree or higher, and three years of experience in clinical documentation improvement. - Mastery level certification through AHIMA or AAPC, and two years of experience in clinical documentation improvement. - Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement. Demonstrated KSAs - Knowledge of coding and documentation concepts, guidelines, and clinical terminology. - Knowledge of anatomy and physiology, pathophysiology, and pharmacology to interpret and analyze all information in a patient's health record. - Ability to collect and analyze data and present results in various formats. - Ability to establish and maintain strong verbal and written communication with providers. - Knowledge of regulations that define healthcare documentation requirements. - Extensive knowledge of coding rules and regulations, including current clinical classification systems. - Knowledge of severity of illness, risk of mortality, complexity of care for inpatients, and CPT Evaluation and Management (E/M) criteria. - Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development. Physical Requirements See VA Directive and Handbook 5019, Employee Occupational Health Service.

Role Description The incumbent will complete thorough psychosocial assessments and include pertinent information in all the required areas of functioning to determine the appropriate diagnoses and other treatment-related conclusions. The clinical assessments must be appropriate to the referral questions. Conclusions are found to be reasonably substantiated by interviews, observations, historical data, collateral data (i.e., from outside sources such as other treatment providers, family members, etc.) and other data when indicated. - Clinical BHIP Responsibilities (60% of time) - Clinical Community Living Center (CLC) Support (30% of time) - Administrative Responsibilities (10% of time) The incumbent may be asked to complete Mental Health evaluations as part of transplant referral. - Provide DSM diagnoses to determine the appropriate treatment needs of the Veterans and/or their families. - Provide emergency/crisis interventions to stabilize Veterans. - Provide psychotherapy as individual, group &/or family interventions when clinically indicated/appropriate. - Provide consultation to other treatment team and staff members regarding psychosocial needs of Veterans and/or their families. - Perform remote psychological testing when clinically appropriate. - Document direct Veteran care at a minimum of 80% of the time allotted to direct care. - Establish and maintain effective therapeutic relationships with Veterans and/or their families. - Promote effective working relationships with co-workers, supervisors, and other Medical Center staff. - Participate in multidisciplinary team meetings regularly and effectively. - Additional duties may be assigned by Mental Health and Behavioral Services. Work Schedule: Monday-Friday 8:00am-4:30pm Central Standard Time EDRP Authorized: Former EDRP participants ineligible to apply for incentive. Contact: visn15edrp@va.gov , the EDRP Coordinator for questions/assistance. Qualifications - Citizenship: Be a citizen of the United States. - Education: - Doctoral degree in psychology from an accredited program. - Or a doctoral degree in any area of psychology with a completed re-specialization program. - Or a doctoral degree awarded between 1951 and 1978 from a regionally-accredited institution. - Internships: Successful completion of a professional psychology internship training program accredited by APA or CPA. - Licensure: Hold a full, current, and unrestricted license to practice psychology. - Board Certification: Required for specific applicants based on internship accreditation. - English Language Proficiency: Must be proficient in spoken and written English. Requirements - At least two years of experience as a professional psychologist, with at least one year equivalent to the GS-12 grade level. - Demonstrated Knowledge, Skills, and Abilities: - Knowledge of professional psychological treatments. - Ability to provide professional advice and consultation. - Knowledge of clinical research literature. Benefits - Competitive salary and regular salary increases. - Paid Time Off: 37-50 days of annual paid time off per year. - Parental Leave: Up to 12 weeks of paid parental leave after 12 months of employment. - Child Care Subsidy: Eligible for a childcare subsidy after 60 days of employment. - Retirement: Traditional federal pension and federal 401K with contributions by VA. - Insurance: Federal health/vision/dental/term life/long-term care insurance options. - Telework: Adhoc Telework Only as Needed. - Remote: This position is remote work eligible. - Virtual: This is NOT a virtual position.