Registered Nurse - Clinical Documentation Integrity Specialist(PRN)
CVP (Customer Value Partners)
PRN Registered Nurse Clinical Documentation Integrity Specialist
CVP is seeking a PRN Registered Nurse Clinical Documentation Integrity Specialist to provide back up coverage to our team at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, TN. This RN will support the Veterans Health Administration's Clinical Documentation Integrity program by ensuring accurate and complete documentation for both inpatient and outpatient services.
Responsibilities
- Act as the Registered Nurse Advisor for the facility's CDI program, focusing on both inpatient and outpatient services
- Review health records concurrently to identify opportunities for improved documentation and coding accuracy using clinical knowledge and critical thinking skills
- Support CDI activities by applying the nursing process to data gathered by the CDI team, reviewing it for clinical validation, trends, and opportunities for improvement
- Communicate findings to the CDI team, providers, and other departments as appropriate
- Collaborate with healthcare providers through written, verbal, or electronic clarification requests or queries
- Develop and implement the facility's CDI management program, including charter, Standard Operating Procedures (SOW), workflow, and turnaround time compliance
- Focus on updating problem lists or Scientific Nomenclature of Medicine – Clinical Terminologies (SNOMED-CT) consistent with ICD-10 CM code sets
- Conduct concurrent or retrospective reviews of health records to clarify clinical questions and identify potential query opportunities
- Develop and deliver active training/education programs for clinical staff about current documentation standards and improving techniques
- Provide self-directed support to clinical staff, patients, and families throughout the continuum of care
- Generate weekly, bi-monthly, and monthly reports as required by the COR
- Maintain performance metrics in accordance with VHA requirements
- Participate in collaborative meetings and CDI-specific program initiatives
Qualifications
- Must be a U.S. citizen and eligible to obtain a Public Trust government security clearance
- Bachelor's degree in Nursing from an accredited program
- Current, full, active and unrestricted RN license in any State, Territory, or Commonwealth of the United States
- Minimum of two years' experience working as a CDI specialist in a hospital setting
- Certification from American Health Information Management Association (AHIMA) and/or American Academy of Professional Coders (AAPC) and/or Association of Clinical Documentation Integrity Specialists (ACDIS)
- Knowledge of ICD-10-CM and MS-DRG coding systems
- Experience with electronic health record systems, particularly VistA/CPRS preferred
- Thorough understanding of medical terminology, anatomy, physiology, disease processes, and treatment protocols
- Knowledge of regulatory guidelines including The Joint Commission, CMS, and VHA requirements
- Excellent communication, interpersonal, and critical thinking skills
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