Registered Nurse - Clinical Documentation Educator

Department of Veterans Affairs

The Central Iowa VA seeks a Clinical Documentation Educator (CDE) Registered Nurse (RN) specializing in Clinical Documentation Improvement (CDI). This RN provides clinical expertise and leadership to achieve facility program goals, improving patient care, and safety. The CDE reviews inpatient medical records to ensure accurate, up-to-date documentation that reflects the patient's severity of illness, clinical treatment, and supports quality patient outcomes.

• Major duties include but are not limited to: Knowledge of the Utilization management process & practical experience in the application of UM methods and expertise in clinical documentation. Ensures the medical record accurately reflects risk of mortality, Case Mix Index (CMI), diagnosis related group (DRG), and Veteran's Equitable Resource Allocation (VERA) funding. Facilitates improved overall clinical documentation quality by ensuring the documentation is reflective of the level of services provided and is accountable for using a variety of collaborative strategies with members of the interdisciplinary team, including frequent interactions with providers, and collaboration with coders to ensure accurate and concise coding aligning with documentation. Provides leadership for and participates in performance improvement activities, using performance improvement methodologies and education strategies to develop formal training improvement programs for the clinical staff concerning clinical documentation opportunities. Possess the ability to interact with a wide variety of employees and to work independently in accomplishing assignments and program goals. Executes position responsibilities that demonstrate leadership, experience, and creative approaches to management of complex utilization processes. Possess strong interpersonal communication skills to instruct staff in medical necessity criteria, documentation thereof and interact with all levels of clinical administrative leadership across the facility. Possess strong analytical skills and the ability to evaluate program structure, process, and effectiveness and recommend strategies for program improvement. Responsible for participating in field program review activities and providing advanced clinical and administrative recommendations and consultation to local staff. Experienced in performance improvement and/or systems redesign methodology and use this knowledge to guide system improvement and /or systems redesign methodology and use this knowledge to guide system improvements in process and resource use at the local and network level. 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, 0700-1530 Compressed/Flexible: Not Available Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized Preferred Experience: Prior experience reviewing provider clinical documentation. Prior clinical experience and knowledge to determine how provider and nursing documents impacts coding, billing, and patient outcomes. Prior experience providing education both formally & informally to providers and clinical staff. Prior experience supporting transition(s) to electronic health record across the facility. The VA Midwest Health Care Network advocates for a Whole Health System of care in each of the Medical Centers. This is an approach to healthcare that empowers and equips people to take charge of their health and well-being and live their lives to the fullest. As an employee operating in a Whole Health System of care, you will operate in a model with three core elements, seeking to create a personalized health plan for each Veteran. This is done in the context of healing relationships and healing environments and a connection back to the Veteran's community. This aligns with the Veterans Health Administration (VHA) Mission Statement to Honor America's Veterans by providing exceptional health care that improves their health and well-being.

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