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.