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. Responsibilities 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. Requirements Conditions of Employment U.S. Citizenship; non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment. Applicants who refuse to be tested will be denied employment with VA. Selective Service Registration is required for males born after 12/31/1959. Subject to background/security investigation. Selected applicants will be required to complete an online onboarding process. Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents). Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment. Must pass pre-employment physical evaluation. Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). You may be required to serve a probationary period. Complete all application requirements detailed in the "Required Documents" section of this announcement. 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/13049761. 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: 3-5 years in acute inpatient care (ICU, CCU, ED, or Med-Surg) BSN or MSN CCDS (ACDIS) or CDIP (AHIMA) certification Background in Utilization Review, Case Management, or chart auditing Physical Requirements: This position includes a level of physicality normally associated with duties performed by nurses such as direct patient care, and potentially long periods of walking, standing, sitting, moderate lifting, repeated bending, or kneeling. Examples may include but are not limited to: - Significant amounts of time standing assisting assigned patients - Utilization of safe patient handling and mobility protocols This includes but is not limited to carrying/lifting 45 pounds and over; walking and/or standing for eight hours at time; and kneeling and repeated bending throughout shift. Education Additional Information This job opportunity announcement may be used to fill additional vacancies. This position is in the Excepted Service and does not confer competitive status. VA encourages persons with disabilities to apply. The health-related positions in VA are covered by Title 38, and are not covered by the Schedule A excepted appointment authority. If you are unable to apply online or need an alternate method to submit documents, please reach out to the Agency Contact listed in this Job Opportunity Announcement. Under the Fair Chance to Compete Act, the Department of Veterans Affairs prohibits requesting an applicant's criminal history prior to accepting a tentative job offer. For more information about the Act and the complaint process, visit Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP) at The Fair Chance Act.
