Company Overview:

Paradigm Professional Health Services, Inc. (Paradigm) is a government contractor specialized in providing qualified, reliable, and culturally competent health and education professionals to meet the mission objectives of federal agencies nationwide.

Position Overview:

Paradigm currently has an opening for a full-time (40 hours/week) Clinical Documentation Specialist (CDS) or Clinical Documentation Improvement Specialist (CDIS) to provide ON-SITE auditing services for the Veterans Administration (VA) San Diego Healthcare System. The CDS/CDIS will be responsible for abstracting medical record data and assigning codes using current clinical classification systems for the type of care provided. 

Period of Performance:

Base Year #: 07/01/2024 – 06/30/2025

Option Year #1: 07/01/2025 – 06/30/2026

Option Year #2: 07/01/2026 – 06/30/2027

Option Year #3: 07/01/2027 – 06/30/2028

Option Year #4: 07/01/2028 – 06/30/2029

Places of Performance:

VA San Diego Healthcare System

3350 La Jolla Village Dr.

San Diego, CA 92161

Hours of Work:

Monday - Friday; 7:30 AM to 4:00 PM

Required Qualifications:

• Asbestos Certification (CDIS must be willing to complete an asbestos training course at the time of submitting application. Paradigm will pay for the cost of the course). (Required)
• Able to start work immediately after background security check is cleared; 
• CDIS, CCDS, or CPC certification (Preferred);
• 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 heath record;
• Knowledge of anatomy and physiology, pathophysiology, and pharmacology;
• Ability to establish and maintain strong verbal and written communication with providers;
• Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines;
• Knowledge of coding rules and requirements to include clinical classification systems (such as current versions of ICD and CPT), complication or co morbidity/major complication or co-morbidity (CC/MCC), Medicare Severity Diagnosis Related group (MS-DRG) structure, and Present on Admission (POA) indicators;
• Knowledge of severity of illness and risk of mortality indicators; and
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development. The training sessions may be technical in nature or may focus on teaching techniques for the improvement of clinical documentation issues.

Essential Duties and Responsibilities:

• Knowledge and experience of coding using ICD 9 and ICD 9.
• Develop and/or update healthcare system policy memorandum pertaining to documentation improvement.
• Serve as technical expert in health record content and documentation requirements.
• Perform reviews of the health record documentation; developing criteria, collecting data, graphing and analyzing results, creating reports and communicating in writing and/or in person to appropriate leadership and groups.
• Obtain appropriate corrective action plans from responsible clinical services directors, when necessary, and recommend improvements or changes in documentation as deemed necessary.
• Adhere to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policy and medical-legal requirements.
• Develop and implement active training/education programs (i.e. seminars, workshops, short courses, informational briefings, and conferences) for all providers to ensure the CDIS program objectives are met.

NON-DISCRIMINATION POLICY

Paradigm is an equal opportunity employer and makes all employment decisions, including those related to recruitment, hiring, training, promotion, and recognition of individuals on the basis of their ability and job-related qualifications and without regard to race, gender, religion, national origin, sexual orientation, disability, or any other classification proscribed under applicable federal, state, or local law.

The availability of this position is based on contract award.

Close Date: May 27, 2024 @ 10PM (PST)