Registered Nurse - Clinical Documentation Improvement Advisor

Summary

The Clinical Documentation Improvement Registered Nurse Advisor (CDI RNA) demonstrates leadership, experience, and creative approaches for quality care initiatives utilizing clinical documentation improvement processes to enhance veterans' quality-of care outcomes.

Duties

The CDI RNA is accountable for using a variety of collaborative strategies with Physicians, APRNs, PAs, and other multidisciplinary team members, Medical Care Cost Recovery (MCCR), Health Information Management Services (HIMS), and Veterans Equitable Resource Allocation (VERA) staff to ensure the level of severity of illness and level of service provided are accurately reflected in the medical record. The CDI RNA is responsible for activities in the inpatient and outpatient CDI program areas at the Martinsburg VA Medical Center and all offsite CBOCs. The CDI RNA collects data and monitors compliance within clinical staff documentation, utilizing current ICD-10-CM, ICD-10-PCS, CPT, and HCPCS documentation and coding guidelines, VHA coding and documentation guidelines, policies, and Joint Commission standards. The CDI RNA provides reports detailing documentation trends and provides all clinical staff education and coding guidance to ensure a comprehensive clinical documentation improvement program. The CDI RNA participates in several facility documentation improvement councils, committees, and work groups. Duties require the ability to apply specialized documentation and coding principles and support quality healthcare delivery by performing clinical documentation record reviews for both inpatient and outpatient services. The CDI RNA will be required to perform clinical rounds with clinical staff within the Martinsburg hospital facility and at various CBOCs. The CDI RNA will also send queries when necessary, during clinical validation, chart discussions with providers during a second-level chart review, or other processes that require a query. The focus of the CDI RNA is to analyze and trend CDI query metrics, mortality reviews, and documentation and coding discrepancies to provide education to providers on documentation opportunities identified by query processes, record reviews, and other metrics. Duties also include assisting with clinical education of CDI specialist and Coders on identification of clinical indicators and assisting with newsletters or other communication vehicles to further educate clinical staff. The CDI RNA functions as an advisor and analyst for clinical documentation improvement activities. The CDI RNA supports CDI activities by applying the nursing process to data gathered by the CDI team, reviewing it for clinical validation, trends, and opportunities for improvement, and communicating this information back to the CDI team, providers, and other departments as appropriate. The CDI RN's role and responsibilities also include knowledge of Utilization Management and Utilization Review processes, clinical documentation requirements, Joint Commission standards of care, ICD-10-CM, ICD-10-PCS, HCPCS, CPT code assignment and coding compliance guidelines, DRGs, and third-party payment and denial regulations. In addition, the incumbent is accountable for maintaining a thorough knowledge of the VHA Resident Supervision Documentation Guidelines, Joint Commission documentation standards, Centers for Medicare and Medicaid Services requirements, and VA guidelines for medical record functions. Veteran, family, medical staff, community partners, etc. Delegates elements of care to the appropriate individual based upon assessed needs, condition, and safety of the patient. Supports colleagues and other nurses through knowledge sharing to provide provide safe, quality nursing care. Fosters a safe and supportive environment conducive to the professional development of health care professionals. Evaluates outcomes of evidence-based decisions and practice changes for individuals, groups, and populations. Responsible for the documented outcomes at the program or service level. Program or service level outcomes must be broad and complex and can be demonstrated at any organizational level within a facility. 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: 7:30 am - 4:00 pm, Monday - Friday Telework: Not Available. Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized. Permanent Change of Station (PCS): Not Authorized.

Requirements

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 and evaluation

IN DESCRIBING YOUR EXPERIENCE, PLEASE BE CLEAR AND SPECIFIC. WE MAY NOT MAKE ASSUMPTIONS REGARDING YOUR EXPERIENCE. Your application, resume, C.V., and/or supporting documentation will be verified. Please follow all instructions carefully. Errors or omissions may affect consideration for employment. NOTE: Candidate's education, scope, and length of nursing practice (experience) will be considered in determining the grade and salary of the applicant selected. The recommended salary may be at any point in the range listed for this vacancy. Experience as an RN will be evaluated to determine if the experience is of an acceptable level of quality with regard to the following five dimensions of nursing: Practice, Veteran/Patient Driven Care, Leadership, Professional Development, and Evidence/Based Practice/Research. Each dimension of practice has criteria that demonstrate essential core competencies for VHA Nursing Personnel. Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religions; spiritual; community; student; social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience. The Department of Veterans Affairs performs pre-employment reference checks as an assessment method used in the hiring process to verify information provided by a candidate (e.g., on resume or during interview or hiring process); gain additional knowledge regarding a candidate's abilities; and assist a hiring manager with making a final selection for a position. It is the policy of the VA to not deny employment to those that have faced financial hardships or periods of unemployment. Veterans and Transitioning Service Members: Please visit the VA for Vets site for career-search tools for Veterans seeking employment at VA, career development services for our existing Veterans, and coaching and reintegration support for military service members.

How to apply

All applicants are encouraged to apply online. To apply for this position, you must complete the full questionnaire and submit the documentation specified in the Required Documents section below. The complete application package must be submitted by 11:59 PM (ET) on 11/03/2026 to receive consideration. To preview the questionnaire, click https://apply.usastaffing.gov/ViewQuestionnaire/13102744. To begin, click Apply Online to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USA JOBS resume and/or other supporting documents and complete the occupational questionnaire. Click Submit My Answers to submit your application package. NOTE: It is your responsibility to ensure your responses and appropriate documentation are submitted prior to the closing date. During the application process you may have an option to opt-in to make your resume available to hiring managers in the agency who have similar positions. Opting in does not impact your application for this announcement, nor does it guarantee further consideration for additional positions.

Required documents

To apply for this position, you must provide a complete Application Package which includes: Long-form resume/Curriculum vitae (CV) The following documents are accepted and may be required if applicable to your eligibility and/or qualifications for this position. Cover Letter DD-214/ Statement of Service Disability Letter (Schedule A) Disability Letter (VA) License Long-form resume/Curriculum vitae (CV) Other (1) PCS Orders Performance Appraisal Professional Certification Separation Notice (RIF) SF-15 SF-50/ Notification of Personnel Action Transcript Veterans' Preference Note: Preference eligible candidates and other Veterans will be given preference when qualification of candidates are approximately equal for Title 38 positions in VHA. When applying for Federal Jobs, eligible Veterans should claim preference for 5pt (TP), 10pt (CP/CPS/XP), or for Sole Survivor Preference (SSP) in the questionnaire. You must provide a legible copy of your DD214(s) which shows dates and character of service (honorable, general, etc.). If you are currently serving on active duty and expect to be released or discharged within 120 days you must submit documentation related to your active duty service which reflects the dates of service, character of service (honorable, general, etc.), and dates of impending separation. Additionally, disabled veterans and others eligible for 10-point preference (such as widows or mothers of eligible Veterans) must also submit an SF-15 "Application for 10 Point Veteran Preference" with required proof as stated on the form. Documentation is required to award preference. For more information on Veterans' Preference, please visit Feds Hire Vets - Veterans - Job Seekers - Veterans' Preference.

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. Whole Health is an approach to health care that empowers and equips people to take charge of their health and well-being and live their life to the fullest. The VA is committed to Whole Health and values Veteran and Employee health and wellbeing. As a VA employee, you will practice Whole Health in an environment that supports personalized and proactive care.