Clinical Documentation Improvement RN Advisor

Full Job Description

The Clinical Documentation Improvement RN Advisor (CDI RN) supports CDI Program which strives to promote accurate and complete documentation in the health record.

The CDI RN is a lead participant in performance improvement activities and develops/delivers formal training for medical staff concerning clinical documentation opportunities, coding, and reimbursement issues.

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.

Preferred Experience: BSN or Higher preferred 3-5 years of clinical experience preferred Program management experience preferred Data management experience preferred 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/12912203.

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: VA Regulations, specifically VA Handbook 5005, Part II, Appendix G-6 Nurse Qualification Standard.

This can be found in the local Human Resources Office. Physical Requirements: Walking, bending, stooping, and some lifting in the direct care of patients. There may also be extended periods of sitting.

This position also requires that the staff member be able to wear a lead apron for an extended period of time. Major Duties:

They work closely with other members of the CDI team.

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

The CDI RN facilitates improvements to clinical documentation by interacting with providers and other members of the healthcare team through data analysis and education.

The CDI RN provides education to enhance the knowledge of the CDIS, coding staff, healthcare teams or providers on identification of disease processes that reflect severity of illness, complexity, and acuity to facilitate accurate application of code sets.

The CDI RN role is complex and requires expert knowledge in areas of clinical care, applicable coding guidelines and quality standards, as well as an ability to communicate effectively with the clinical care team and provide guidance in developing appropriate policies/ procedures.

The CDI RN promotes capture of clinical severity (later translated into coded data) to support the level of service rendered to relevant patient populations.

The CDI RN reviews physician queries as initiated by the coders, to identify those areas of documentation needing further clarification, to improve patient care.

The CDI RN develops, completes, and coordinates internal monitoring and auditing activities to oversee compliance with documentation, coding, billing issues and VERA capture.

VA offers a comprehensive total rewards package: VA Nurse Total Rewards Work Schedule: 0730 to 1600. Telework: Yes, Ad-Hoc, as determined by the agency policy.

Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Financial Disclosure Report: Not required