The Clinical Documentation Integrity (CDI) nurse serves as an expert practitioner whose practice encompasses a wide range of responsibility and accountability. The effect of the CDI Nurse practice goes beyond any individual unit or team to encompass programs, services, or service lines. The CDI nurse is part of the Quality, Safety & Value (QSV) team in the Office of the Executive Director. Basic Requirements: United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. English Language Proficiency. In accordance with 38 U.S.C. 7402(d), 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 State-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). In cases of graduates of foreign schools of professional nursing, possession of current, full, active and unrestricted registration will meet the requirement of graduation from an approved school of professional nursing. OR The completion of coursework equivalent to a nursing degree in a MSN Bridge Program that qualifies for professional nursing registration constitutes the completion of an approved course of study of professional nursing. Students should submit the certificate of professional nursing to sit for the NCLEX to the VA along with a copy of the MSN transcript. (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. 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. Preferred Experience: Quality related certifications to include but not limited to Certified Clinical Documentation Specialist, Certified Professional in Healthcare Quality, Certified InterQual instructor, Certified Professional in Patient Safety, and Lean Six Sigma or other process improvement certifications (Yellow, Green, or Black Belt). Experience in Clinical Documentation Review, Utilization Management, Utilization Review, InterQual or Milliman, and Microsoft Excel. Experience as a Nurse Manager, Program Manager, or Educator/Trainer also preferred. Grade Determinations: The following criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade: Nurse I Level I - An Associate Degree (ADN) or Diploma in Nursing, with no additional nursing practice/experience required. Nurse I Level II - An ADN or Diploma in Nursing and approximately 1 year of nursing practice/experience; OR an ADN or Diploma in Nursing and a bachelor's degree in a related field with no additional nursing practice/experience; OR a Bachelor's of Science in Nursing (BSN) with no additional nursing practice/experience. Nurse I Level III - An ADN or Diploma in Nursing and approximately 2-3 years of nursing practice/experience; OR an ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 1-2 years of nursing practice/experience; OR a BSN with approximately 1-2 years of nursing practice/experience; OR a Master's degree in nursing (MSN) or related field with a BSN and no additional nursing practice/experience. Nurse II - A BSN with approximately 2-3 years of nursing practice/experience; OR ADN or Diploma in Nursing and a Bachelor's degree in a related field and approximately 2-3 year's of nursing practice/experience; OR a Master's degree in nursing or related field with a BSN and approximately 1-2 year's of nursing practice/experience; OR a Doctoral degree in nursing or meets basic requirements for appointment and has doctoral degree in a related field with no additional nursing practice/experience required. Nurse III - Master's degree in nursing or related field with BSN and approximately 2-3 year's of nursing practice/experience; OR a Doctoral degree and approximately 2-3 year's of nursing practice/experience. 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: All applicants must be physically and mentally able to perform efficiently the duties of the position. Must be able to lift (30 lbs or more); twisting and/or bending, standing. This position requires visual acuity, keen hearing, clear distinctive speech, and manual dexterity. This position requires potentially long periods of continued walking, standing, stooping, sitting, bending, pulling, and pushing. Transferring patients and objects may be required. The incumbent may be exposed to infected patients and contaminated materials and may be required to don protective clothing in isolation situations or operative/invasive procedures. The incumbent may occasionally be exposed to patients who are combative secondary to delirium, dementia, or psychiatric disorders. The incumbent must be a mature, flexible, sensible individual capable of working effectively in stressful situations, able to shift priorities based on patient needs. The incumbent must complete all annual Employee Health requirements, such as annual TB Screening or testing, as a condition of employment. ["QSV also includes Quality Consultants, Accreditation Readiness, Utilization Management, Patient Safety, Risk Management, and High Reliability Organization (HRO) staff. At this level, the QSV Nurse initiates and participates with interdisciplinary projects, committees, teams, etc., with the aim of improving outcomes in the management of complex client care or the systems and processes of the organization. The QSV Nurse is recognized as a leader and consistently demonstrates that leadership in quality improvement activities, self-direction, initiative, planning, implementing, evaluating, and improving holistic care delivery using collaborative strategies with others while ensuring compliance with facility and VISN mission and nationally recognized standards. Clinical Documentation Integrity (CDI) Nurse Duties: Serves as a clinical champion to support the overall CDI program, providing a clinical perspective, and bridging the gap between the coders, CDI specialists, and providers. Recommends changes, policies, or programs that could enhance CDI. Provides ongoing training to CDI staff on identification of clinical indicators for disease processes. In collaboration with CDI staff, designs and presents provider training programs to increase CDI awareness and compliance. Conducts concurrent or retrospective health record reviews in support of CDI staff to clarify clinical questions and/or illuminate potential query opportunities. Aid in the health record review process, quality assurance, mortality reviews, CMS core measures, and other quality initiatives. Conducts analysis of coded data and provider documentation primarily used to determine, measure, and report severity and risk adjusted outcomes and cost for various metrics to include VERA patient class assignment, length of stay, complications, mortality, and readmissions. Demonstrates dedication to the nursing profession and represents nursing in the community and professional activities. Assures that nursing practices are in accordance with, and adhering to, regulations such as the Nurse Practice Act, VHA policies and procedures, and the standards of outside accrediting bodies. Performs other duties as assigned by QSV leadership. (NY67 Clinical Quality pay scale) 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: Monday -Friday Day hours Telework: Not available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not authorized Permanent Change of Station (PCS): Not authorized Financial Disclosure Report: Not required"]
About Veterans Affairs, Veterans Health Administration
Providing Health Care for Veterans: The Veterans Health Administration is America’s largest integrated health care system, providing care at 1,255 health care facilities, including 170 medical centers and 1,074 outpatient sites of care of varying complexity (VHA outpatient clinics), serving 9 million enrolled Veterans each year.