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4.1 Contractor must provide an individual who will perform duties consistent with the Veterans Equitable Resource Allocation (VERA) and Clinical Documentation Improvement (CDI) Advisor including: review of current processes, development and deployment of plan including standard operating procedures for the VERA Coordinator and appropriate Health Information Management's (HIM) staff (as well as other facility staff as needed) to ensure optimization of workload collection for funding allocation and revenue collection, as well as accurate documentation and coding. Contractor acts as a liaison between the CDIS, HIM, and the clinical staff to facilitate accurate and timely documentation for coding, MS-DRG assignment, and representation of severity, acuity, and risk of mortality. Individual will collect and organize information required for preparation of user's manuals, training materials, installation guides, proposals, and reports. Individual may edit functional descriptions, system specifications, user manuals, special reports, or other deliverables/documents. Individual will manage all aspects of materials preparation.
4.2 Individual is the technical advisor to Client and clinical services providing guidance, recommendations, and monitoring of the implementation, management and evaluation of VERA and coding oversight programs, ensuring programs meet standards/criteria. Working toward optimization, the individual will work with VERA and HIMs staff to establish a systems-wide management information system that ensures the capture of cost, workload/VERA, and coding data, providing information in a format that is useful to facility management officials and various councils for evaluating resource utilization and VERA and coding performance in the system.
4.3 The individual will work closely with the VERA Coordinator, Chief Health Information Management (HIMs), Coding Compliance Specialist, and Coding Documentation Improvement Liaisons (RN-Informatics) or designee and be highly responsive relative to the daily activities of the office. Individual is expected to work independently with minimal detailed supervision and guidance. Work requires knowledge of office routine and understanding of the organization, programs, and procedures of the VERA and coding programs, and those related in both administration and clinical operations. Individual needs experience with Word, Excel, and PowerPoint as well as VHA specific software such as CPRS and VistA.
4.4 Contractor must have a full working knowledge of the of facility workload peculiarities, process, complexity from start to finish. The contractor will train VA physicians and residents on the workload process through VISTA through HL-7 ensuring the data hits Austin. Contractor will train physicians on VHA quality indicators (SAIL-Strategic Analytics for Improvement and Learning Value Model and VERA), and how those correlate to clinical documentation.
4.5 The Contractor will collaborate with designated revenue staff to optimize third party reimbursement. Contractor collaborates with HIM staff to identify patterns and deficiencies in documentation, lack of specificity, or medical necessity for services rendered. Contractor collaboration includes education that is developed and delivered to providers and support staff.
4.6 Contractor will collaborate with the health care provider through written, verbal, or electronic clarification requests or queries. Requesting clarification from providers regarding clinical documentation is one of the primary tools used by the contractor to improve clinical documentation in the health record. Guidance for establishing provider queries is included in VHA Handbook 1907.01, Health Information Management and Health Records, VHA HIM Clinical Coding Program Guide, VHA Coding Guidelines, and VHA HIM Practice Brief, Provider Query Process. The health record is reviewed to determine the specific reason for the encounter, the conditions treated, and any procedures performed that support appropriate code assignment in the inpatient or outpatient setting.
4.7 Contractor creates CDI specific topics and education materials for Medical Center newsletter or other communication vehicles to further educate the clinical staff. Collaborates with HIM and CDIS on a routine basis to review selected health records concurrently or retrospectively. Reviews documentation issues identified during chart reviews including common issues such as congestive heart failure, chronic kidney disease, urosepsis, pneumonia, anemia, and respiratory failure which may represent opportunities for improvement. Helps develop clinically appropriate and compliant facility provider queries to further clarify documentation. Facilitates complete and timely health record documentation by aiding in the health record review process, quality assurance, CMS core measures, and other initiatives. Provides data analysis of coded data primarily used to determine, measure, and report severity and risk adjusted outcomes and cost data for various metrics. These include cost, Veterans Equitable Resource Allocation (VERA) patient class assignment, length of stay, complications, mortality and readmissions.
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