Registered Nurse - Clinical Documentation Improvement Advisor

Veterans Health Administration; Martinsburg (WV); Vor Ort; USD 71.000 - 136.000; Vollzeit

Benefits dieser Stelle

Paid Time Off

Federal benefits

Health insurance

Licensure support

Work schedule

Zusammenfassung

U.S. Department of Veterans Affairs in Martinsburg, WV seeks a Registered Nurse - Clinical Documentation Improvement Advisor to lead CDI efforts across inpatient and outpatient care.

The role collaborates with physicians, APRNs, PAs, and HIMS/VERA teams to ensure accurate severity of illness and level of service in medical records. Responsibilities include data collection, documentation trend reporting, staff education, and ongoing queries during validation.

Qualifikationen

• Nursing degree and licensure in good standing.
• Experience with clinical documentation improvement programs.
• Ability to educate and inform clinicians on documentation and coding.

Aufgaben

• Lead CDI program activities for inpatient and outpatient services.
• Collaborate with physicians, APPs, PAs, and other staff to ensure accurate documentation.
• Provide reports on documentation trends and education to staff.
• Conduct clinical rounds and patient chart reviews.
• Send queries during clinical validation and chart reviews.
• Contribute to newsletters and material to educate staff.

Kenntnisse

Clinical documentation improvement

Nursing leadership

Interdisciplinary collaboration

Ausbildung

BSN or higher nursing degree

Tools

ICD-10-CM/PCS

CPT/HCPCS coding guidelines

Jobbeschreibung

Registered Nurse - Clinical Documentation Improvement Advisor

• Department: Department of Veterans Affairs

The Clinical Documentation Improvement Registered Nurse Advisor (CDI RNA) demonstrates leadership, experience, and creative approaches for quality care initiatives utilizing clinical documentation improvement processes to enhance veterans' quality-of care outcomes.

Key Responsibilities

The CDI RNA is accountable for using a variety of collaborative strategies with Physicians, APRNs, PAs, and other multidisciplinary team members, Medical Care Cost Recovery (MCCR), Health Information Management Services (HIMS), and Veterans Equitable Resource Allocation (VERA) staff to ensure the level of severity of illness and level of service provided are accurately reflected in the medical record.

The CDI RNA is responsible for activities in the inpatient and outpatient CDI program areas at the Martinsburg VA Medical Center and all offsite CBOCs. The CDI RNA collects data and monitors compliance within clinical staff documentation, utilizing current ICD-10-CM, ICD-10-PCS, CPT, and HCPCS documentation and coding guidelines, VHA coding and documentation guidelines, policies, and Joint Commission standards.

The CDI RNA provides reports detailing documentation trends and provides all clinical staff education and coding guidance to ensure a comprehensive clinical documentation improvement program. The CDI RNA participates in several facility documentation improvement councils, committees, and work groups.

Duties require the ability to apply specialized documentation and coding principles and support quality healthcare delivery by performing clinical documentation record reviews for both inpatient and outpatient services. The CDI RNA will be required to perform clinical rounds with clinical staff within the Martinsburg hospital facility and at various CBOCs.

The CDI RNA will also send queries when necessary, during clinical validation, chart discussions with providers during a second-level chart review, or other processes that require a query. The focus of the CDI RNA is to analyze and trend CDI query metrics, mortality reviews, and documentation and coding discrepancies to provide education to providers on documentation opportunities identified by query processes, record reviews, and other metrics.

Duties also include assisting with clinical education of CDI specialist and Coders on identification of clinical indicators and assisting with newsletters or other communication vehicles to further educate clinical staff. The CDI RNA functions as an advisor and analyst for clinical documentation improvement activities.

The CDI RNA supports CDI activities by applying the nursing process to data gathered by the CDI team, reviewing it for clinical validation, trends, and opportunities for improvement, and communicating this information back to the CDI team, providers, and other departments as appropriate.

The CDI RN's role and responsibilities also include knowledge of Utilization Management and Utilization Review processes, clinical documentation requirements, Joint Commission standards of care, ICD-10-CM, ICD-10-PCS, HCPCS, CPT code assignment and coding compliance guidelines, DRGs, and third-party payment and denial regulations.

In addition, the incumbent is accountable for maintaining a thorough knowledge of the VHA Resident Supervision Documentation Guidelines, Joint Commission documentation standards, Centers for Medicare and Medicaid Services requirements, and VA guidelines for medical record functions. Veteran, family, medical staff, community partners, etc. Delegates elements of care to the appropriate individual based upon assessed needs, condition, and safety of the patient.

Supports colleagues and other nurses through knowledge sharing to provide provide safe, quality nursing care. Fosters a safe and supportive environment conducive to the professional development of health care professionals. Evaluates outcomes of evidence-based decisions and practice changes for individuals, groups, and populations. Responsible for the documented outcomes at the program or service level.

Program or service level outcomes must be broad and complex and can be demonstrated at any organizational level within a facility.

VA offers a comprehensive total rewards package:

• VA Nurse Total Rewards Pay: Competitive salary, regular salary increases, potential for performance awards
• Paid Time Off: 50 days of paid time off per year (26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year)
• Retirement: Traditional federal pension (5 years vesting) and federal 401K with up to 5% in contributions
• Insurance: Federal health/vision/dental/term life/long-term care (many federal insurance programs can be carried into retirement)
• Licensure: 1 full and unrestricted license from any US State or territory
• Work Schedule: 7:30 am - 4:00 pm, Monday - Friday
• Telework: Not Available.

Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized. Permanent Change of Station (PCS): Not Authorized.

Which agency is hiring for this position?

This position is with Veterans Health Administration, Department of Veterans Affairs.

What is the salary for this position?

The posted pay range is $70938 – $135855/yr.

What is the application deadline?

Applications close on 2026-11-03.

Who is eligible to apply?

This position is open under the 'Public' hiring path.