Registered Nurse - Clinical Documentation Improvement Advisor

Veterans Health Administration, Department of Veterans Affairs; Martinsburg (WV); Presencial; USD 90.000 - 120.000; Tempo integral

Resumo da vaga

Veterans Health Administration, Martinsburg VA Medical Center, seeks a Clinical Documentation Improvement Registered Nurse Advisor to lead quality care initiatives and optimize clinical documentation to improve veterans' outcomes. You will collaborate with physicians, coders, and care teams to ensure accurate severity of illness and service levels reflected in medical records.

The CDI RNA will monitor documentation, provide education, generate reports, participate in councils, perform chart

Qualificações

• English language proficiency is required.
• Graduate nursing degree with state license or eligibility.
• Ability to apply nursing process and conduct chart reviews.
• Experience with clinical documentation improvement activities is preferred.

Responsabilidades

• Collaborate with physicians, APRNs, PAs, and care teams to ensure accurate documentation.
• Perform inpatient and outpatient CDI activities at Martinsburg facility and offsite clinics.
• Provide education and coding guidance to staff to improve documentation quality.
• Generate reports on documentation trends and participate in CDI committees and work groups.
• Query providers as needed during chart reviews and validations.

Conhecimentos

Leadership

Clinical documentation

Healthcare quality improvement

Staff education

Interdisciplinary collaboration

Data analysis

Regulatory compliance

Formação

Associate Degree in Nursing (ADN)

Diploma in Nursing

Bachelor of Science in Nursing (BSN)

Master of Science in Nursing (MSN)

Registered Nursing License

Ferramentas

ICD-10-CM/PCS

CPT coding

HCPCS coding

Descrição da vaga

Summary

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.

Qualifications

Basic Requirements:

• English Language Proficiency
• In accordance with 38 U.S.C. 7403(f) - no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English
• Graduate of a school of professional nursing approved by the appropriate accrediting agency and accredited by one of the following accrediting bodies at the time the program was completed by the applicant: The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE)
• OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program
• Upon achievement of a State license - the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program
• (Reference VA Handbook 5005 - Appendix G6)
• OR In cases of graduates of foreign schools of professional nursing - possession of a current - full - active - and unrestricted registration will meet the requirement for graduation from an approved school of professional nursing to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program
• Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD)
• Current - full - active - and unrestricted registration as a graduate professional nurse in a State - Territory or Commonwealth (i.e. - Puerto Rico) of the United States - or the District of Columbia
• Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements - but do not possess the required licensure - may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.) NOTE: Grandfathering Provision - All persons currently employed in VHA in 0610 series and performing the duties as described in the qualification standard on the effective date of the standard (1/29/2024) are considered to have met all qualification requirements for the grade held including positive education and licensure/certification
• Grade Determinations: The following Scope - Education and Dimension criteria must be met in determining the grade assignment of candidates - and if appropriate - the level within a grade
• The Dimension requirements (Practice - Veteran/Patient Driven Care - Leadership - Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment: https://apply.usastaffing.gov/ViewQuestionnaire/13102744
• Grade/Level Scope Education Nurse I - Level I Delivers fundamental - knowledge-based care to assigned clients while developing technical competencies
• An Associate Degree (ADN) or Diploma in Nursing - with no additional professional nursing required
• Nurse I - Level II Demonstrates integration of biopsychosocial concepts - cognitive skills and technically competent practice in providing care to clients with basic or complex
• An ADN or Diploma in Nursing AND 1 year of specialized nursing experience equivalent to Nurse I - Level 1 ;OR a Bachelor of Science in Nursing (BSN) with no additional professional nursing experience required
• Nurse I - Level III Demonstrates proficiency in practice based on conscious and deliberate planning
• Self-directed in goal setting for managing complex client situations
• An ADN or Diploma in Nursing AND 2 years of professional nursing experience in which one year is equivalent to Nurse I - Level 2
• OR a BSN and 1 year of professional nursing experience equivalent to the Nurse I - Level 2
• OR a Master's degree in nursing (MSN) and no additional professional nursing experience
• OR a Master's degree in a *related field with a BSN and no additional professional nursing experience
• Nurse II Demonstrates leadership in delivering and improving holistic care through collaborative strategies with others
• A BSN with 2 years of professional nursing equivalent to Nurse I - Level 3
• OR an MSN with one year of specialized nursing experience equivalent to Nurse I - Level 3
• OR a Master's degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse I - Level 3
• OR a Doctoral degree in Nursing with no professional nursing experience
• OR a Doctoral degree in a *related field with a BSN with no additional professional nursing experience
• Nurse III Executes position responsibilities that demonstrate leadership - experience and creative approaches to management of complex client care beyond the immediate practice setting
• MSN and 2 years of specialized nursing experience - one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Master's degree in *related field with BSN and two years of specialized nursing experience - one of which is equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Doctoral degree in Nursing with and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III
• OR a Doctoral degree in a *related field with a BSN and one year of specialized nursing experience equivalent to Nurse II and meets all dimension requirements for Nurse III
• *Note: Foreign education programs/degrees are not creditable as related degrees
• Reference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/
• Preferred Experience: Coding Credentials - Preferred Physical Requirements: See VA Directive and Handbook 5019 - Employee Occupational Health Service for requirements.

Duties

• 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 by VA 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.