Clinical Documentation Reviewer (VA Medical Center – Bay Pines)

This is a remote position.

Position Overview

We are seeking a Clinical Documentation Reviewer to support TUWYN’s contract with the VA Medical Center (Bay Pines). This role focuses on clinical documentation review (not improvement or integrity) to ensure accurate, complete, and compliant documentation for high-risk patients. The position involves participating in daily huddles with VA physicians and interdisciplinary teams, prioritizing reviews for patients with a Care Assessment Need (CAN) Score > 90%, and collaborating to meet VA KPIs.

Key Responsibilities

• Daily Huddle Participation:
  

  • Attend up to three 30-minute huddles daily (Red, Purple, Green teams), Monday–Friday. The first few months will be a Trail period, and if program is successful our team will be asked to attend up to 6 huddles per day.
    
  • Present documentation review findings within a 5-minute window per huddle.
    
  • Engage collaboratively to support documentation improvements and physician priorities.
    

• Clinical Documentation Review:
  

  • Conduct thorough reviews of inpatient charts, focusing on high-risk patients (CAN Score > 90%).
    
  • Re-review charts as needed during patient stays to maintain accuracy and compliance.
    
  • Abstract key clinical information for reporting and quality assurance.
    

• Compliance & Standards:
  

  • Ensure all work adheres to TUWYN contract requirements, using TUWYN or VA.gov email addresses, logos, and documentation templates.
    
  • Maintain confidentiality and comply with HIPAA and VA security protocols.
    

• Collaboration & Coordination:
  

  • Work closely with VA physicians, other CDISs, and interdisciplinary teams to clarify documentation needs.
    
  • Support onboarding of CCDS/CDIP candidates as TUWYN contractors in coordination with HYRE HARPER Co and Samstaff.
    
  • Assist in sharing team feedback and project updates with leadership.
    

• Performance Tracking:
  

  • Contribute to meeting VA KPIs, including review completion rates and turnaround times.
    
  • Provide input for continuous improvement and success metric alignment with VAMC expectations.
    
  • Follow directions on Review Sheets, which are uploaded to a secure file in real time.
    
• Good to know
  
• Reviews have been taking on average 30 minutes. Some reviews have no recommendations and will be quick, some are longer if CAN Score is high. 

Requirements

Qualifications

• Required:
  

  • Active CCDS or CDIP credential.
    
  • Minimum 5 years of clinical documentation review experience in an acute care setting.
    
  • Familiarity with VA systems and CAN Score methodology preferred.
    
  • Strong communication and collaboration skills.
    

• Preferred:
  

  • Active RN, MD, FMG, RHIA, RHIT
    
  • Experience working with government contracts or VA Medical Centers.
    
  • Ability to manage multiple priorities in a fast-paced environment.
    

Work Schedule

• Monday–Friday, Up to three 30-minute huddles daily plus documentation review time. Review's can be completed anytime, 24/7.
  
• Remote with secure VA system access (encrypted email required).
  

Why Join Us?

• Opportunity to contribute to veteran care quality through accurate documentation.
  
• Collaborative team environment with VA physicians and TUWYN leadership.
  
• Professional growth through exposure to federal healthcare standards and KPIs.
  

Benefits