Registered Nurse-Clinical Documentation Integrity Educator

U.S. Department of Veterans Affairs; San Antonio (TX); Hybrid; USD 90,000 - 120,000; Full time

Benefits offered by this job

Telework Available

Competitive salary (VA)

Job summary

The U.S. Department of Veterans Affairs is seeking a Clinical Documentation Integrity Educator Registered Nurse (CDI RN) to lead the clinical documentation program within the South Texas Veterans Health Care System.

This role focuses on improving patient safety and utilization management through advanced nursing expertise and interdepartmental collaboration. The CDI RN Educator will provide guidance, training, and strategic direction to ensure accurate reflection of illness severity and level of

Qualifications

• Proficiency in English per VA requirements.
• Graduate from an ACEN- or CCNE-accredited nursing program.
• Eligible for state RN licensure and eventual permanent appointment.
• Foreign-educated nurses require degree equivalency evaluation when applicable.
• Current, active RN licensure in the U.S. or District of Columbia.

Responsibilities

• Serve as clinical liaison between Health Information Management, Utilization Management, and Medical Center staff.
• Provide leadership for development and maintenance of the medical documentation improvement program.
• Identify opportunities to improve documentation to reflect patient conditions accurately.
• Develop training and education programs for clinical staff on documentation practices.
• Participate in performance improvement activities and initiatives.

Skills

Communication

Leadership

Collaboration

Education

BSN

ADN or Diploma in Nursing

MSN (preferred)

Job description

Summary

The South Texas Veterans Health Care System (STVHCS) Clinical Documentation Integrity Educator Registered Nurse (RN) is a professional nurse who is responsible for providing the clinical expertise and leadership for the implementation of the Medical Center's clinical documentation program goals to improve patient care - patient safety and Utilization Management. The RN reports to the Nurse Manager of Utilization Management and Clinical Documentation Quality and Patient Safety.

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/13075661
• 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 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
• Preferred Experience: -Ability to communicate effectively with internal and external customers -3-5 years of recent Clinical experience -2-5 years of recent Clinical Documentation Improvement experience -Ability to analyze and compile data -2-3 years of experience working with teams and/or programs -Ability to review DRG codes and ICD-10 codes Reference: For more information on this qualification standard - please visit https://www.va.gov/ohrm/QualificationStandards/
• Pre-Employment/Post-Employment Physical Examination: May be required - depending on the needs of the organization.

Duties

• As the Clinical Documentation Integrity Educator Registered Nurse (CDI RN) you will serve as the clinical liaison between Health Information Management - Utilization Management - and the Medical Center staff
• You will possess up-to-date clinical knowledge to review medical records efficiently and concurrently - in conjunction with Utilization Management - to identify opportunities for improved documentation to accurately reflect the specific condition of the Veteran
• Have knowledge of clinical documentation processes and current standards of care
• Accountable for utilizing a variety of collaborative strategies with physicians - mid-level providers - and other members of the interdisciplinary team - to ensure the severity of illness and level of service provided are accurately reflected in the medical record for the delivery of quality patient care services
• Provide leadership for and participate in performance improvement activities
• Use performance improvement methodologies and education strategies to develop formal training improvement programs for the clinical staff concerning medical documentation opportunities
• Provide leadership and assume continuous responsibility for the development - implementation - coordination - maintenance - and evaluation of the medical center's medical documentation improvement program
• 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: Full-time
• Monday-Friday
• 7:00am-3:30pm
• Telework: Available
• Ad-hoc Virtual: This is not a virtual position
• Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized