Registered Nurse - Clinical Documentation Educator

Clinical Documentation Educator (CDE) – Registered Nurse (RN)

The Clinical Documentation Educator (CDE) Registered Nurse (RN) specializes in Clinical Documentation Improvement (CDI) and provides clinical expertise and leadership to improve patient care and safety. This RN reviews inpatient medical records to ensure documentation accuracy, collaborates with interdisciplinary teams and coders, and develops training programs for clinical staff on documentation opportunities.

• English Language Proficiency: Proficient in basic written and spoken English.
• Nursing
  
  Education:
  
  Graduate of an approved professional nursing school accredited by ACEN or CCNE, or a graduate of a master's level bridge program with equivalent coursework.
• Licensure: Full, active, unrestricted RN license in any U.S. state, territory, or Commonwealth. (Special exceptions and bridge program details omitted for brevity.)
• Grade Determinations: Detailed scope and education criteria apply (see official resources).
• Physical Requirements: Participation in pre-employment examination as part of the hiring process.

• Review patients' inpatient medical records concurrently to ensure documentation reflects severity of illness, clinical treatment, and accuracy.
• Ensure medical records accurately reflect risk of mortality, Case Mix Index (CMI), diagnosis related group (DRG), and Veteran's Equitable Resource Allocation (VERA) funding.
• Collaborate with interdisciplinary team members, including frequent interactions with providers and coders, to ensure accurate coding aligned with documentation.
• Provide leadership for and participate in performance improvement activities using performance improvement methodologies.
• Develop and implement formal training improvement programs for clinical staff concerning clinical documentation opportunities.
• Instruct staff in medical necessity criteria and documentation requirements while interacting with all levels of clinical and administrative leadership.
• Participate in field program review activities and provide advanced clinical and administrative recommendations and consultation to local staff.
• Apply Utilization Management (UM) methods and evaluate program structure, process, and effectiveness to recommend improvement strategies.
• Analyze workload data sources and use statistical analysis to guide system improvement in process and resource use.
• Manage multiple priorities while maintaining focus on quality and detail in accomplishing assignments and program goals.

• Salary: Competitive base salary with potential for performance awards.
• Paid Time Off: 50 days of paid time off per year (26 days annual leave, 13 days sick leave, 11 paid Federal holidays).
• Retirement: Traditional federal pension (5 years vesting) and federal 401(k) with up to 5% VA contributions.
• Health & Insurance: Federal health, vision, dental, term life, long‑term care, and other benefits.
• Licensure: 1 full and unrestricted RN license from any U.S. state or territory.
• Work Schedule: Monday–Friday, 7:00 am–3:30 pm.
• Telework: Not applicable.

• Not authorized.

VA is an equal opportunity employer and an affirmative action employer. We welcome applications from all qualified candidates regardless of race, color, religion, sex, sexual orientation, national origin, age, disability, or veteran status.