Registered Nurse - Clinical Documentation Improvement Advisor

Job title: Registered Nurse - Clinical Documentation Improvement Advisor

Responsibilities

• validating documentation
• analyzing data
• developing databases

Requirements

• Requires active unrestricted U.S. RN registration

• Accredited professional nursing education

• English proficiency, and specialized nursing experience. Preferred: 3–5 years acute inpatient care

• BSN/MSN

• CCDS or CDIP, and utilization review

• Case management, or chart auditing

• Technical tools mentioned

• Electronic Medical Records (EMR) Microsoft Excel

• Summary

• The Registered Nurse - Clinical Documentation Improvement Advisor within the Associate Director, Operations service at John Cochran Medical Center in VA Saint Louis Health Care System accurately reflects patient severity, complexity, and acuity in the documentation to support appropriate coding and billing practices. The RN CDI conducts thorough reviews of clinical documentation to ensure accuracy, completeness, and compliance with coding guidelines and quality standards.

Duties

• The Registered Nurse - Clinical Documentation Improvement Advisor within the Associate Director, Operations service at John Cochran Medical Center in VA Saint Louis Health Care System accurately reflects patient severity, complexity, and acuity in the documentation to support appropriate coding and billing practices. The RN CDI conducts thorough reviews of clinical documentation to ensure accuracy, completeness, and compliance with coding guidelines and quality standards. The incumbent demonstrates specialized experience that is characterized by responsibility and accountability for analysis that crosses services and/or discipline lines and influences the organizational mission. The RN CDI follows procedures per established policies and guidelines. They influence outcomes by collaborating with members of the interdisciplinary team. Core elements of performance include knowledge and active participation in the program level quality improvement process and initiatives as well as customer service programs. Duties include, but are not limited to: Validates clinical documentation to accurately reflect the severity of illness, complexity, and acuity of patient care. Identifies and address documentation gaps, ambiguities, or inconsistencies that may impact coding accuracy and reimbursement. Provides feedback to providers and CDI team members on documentation improvement opportunities to enhance compliance. Participates in internal audits to monitor compliance and suggest corrective actions as needed Provides local or regional-level analysis of data to support nursing evaluation and quality endeavors. Demonstrates professionalism by building, supporting, and creating alignments for data management best practices, analytic initiatives and innovation through collaboration and stakeholder engagement. Collects data, analyzes trends, and develops charts that enable the organization to make data driven decisions. Participates in data analysis projects using qualitative and quantitative research methods such as interviews, statistical analysis, surveys, site visits and observations. Investigates and resolves any data discrepancies in a timely manner and presents findings to management. Assists in establishing performance metrics and works with other staff members to identify problem areas and potential solutions. Participates in the development of logical business models and relational databases to programmatically prepare data for analysis. Designs and implements custom algorithms, workflow processes, and layouts for complex, enterprise-scale data sets used for modeling, data mining, and research purposes. Develops and administers databases and/or data management systems that allow for the storage, query, protection, and utilization of data. Validates results and conclusions from experiments and data from research for use in clinical business intelligence systems. Trains staff on the use of software programs. Oversees data management activities, both external and internal. Implements study-specific procedures to ensure compliance with existing regulations and procedures. Designs, deploys, and tests data collection systems. 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: Mon-Fri 7:30 a.m. - 4:00 p.m. Schedule is subject to change based on the needs of the health care system. Telework: Ad hoc per agency policy. Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not authorized. Permanent Change of Station (PCS): Not authorized.

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