Registered Nurse-Quality Management Clinical Documentation Improvement, Quality and Patient Safety

Department of Veterans Affairs

Quality Management and Patient Safety Clinical Documentation Improvement (QM CDI) Registered Nurse (RN) focuses on individual growth and development in practice with increased levels of self-direction. The nurse brings principles and theory with the application of critical thinking skills. The incumbent reviews inpatient and/or outpatient health records concurrently and/or retrospectively to identify opportunities to clarify missing or incomplete clinical documentation.

• Duties include but not limited to: Reviews inpatient and/or outpatient health records concurrently and/or retrospectively to identify opportunities to clarify missing or incomplete documentation. Provides education based on the healthcare record review to providers, case managers, coders and other healthcare team members to facilitate comprehensive health record documentation that reflects clinical treatment decisions, diagnoses, and interventions. Reviews conditions that may impact qualify measures and ensure they are clinically supported by the documentation in the electronic health record. Acts as a consultant to CDI and coding professionals when additional documentation is required to determine the appropriateness of the clinical indicators. Collaborates with HIM/Coding staff to review trends in provider or service-specific cases and outcomes of performance metrics and reports. Ensures accuracy of the final coded data in conjunction with CDI managers, HIM/Coding managers, QM/UR managers, compliance officers and/or physician advisors. Gathers and analyzes information pertinent to documentation findings and outcomes. Prepares and presents summaries of findings to include the impact on performance and quality measures. Conducts independent research to promote knowledge of clinical topics, coding guidelines, regulatory policies and trends. Performs query development, presentation, and standards including understanding published query guidelines and practice expectations for compliance. Acts as an intermediary between the CDIS/coders and medical staff. Participates in departmental and hospital committees and task forces. Captures and reports metrics as identified by facility needs. 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, 0730-1600, flexible to meet the needs of the organization. Compressed/Flexible: Not available. Telework: Ad-hoc Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized. Permanent Change of Station (PCS): Not Authorized.

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