Job Description

Registered Nurse Clinical Documentation Improvement (CDI) Specialist

Ansible Government Solutions, LLC (Ansible) is seeking multiple Registered Nurse Clinical Documentation Improvement (CDI) Specialists to work with us in support of the Orlando VA Medical Center located at 13800 Veterans Way Orlando, FL 32827. The schedule is typically Monday-Friday, 7:30am-4pm. If you accept employment with Ansible, you must also acknowledge that any assigned schedule is subject to change at the direction of either Ansible or its customers.

Ansible is a Service-Disabled Veteran-Owned Small Business (SDVOSB) providing Federal customers with solutions in many arenas. Our customers face wide-ranging challenges in the fields of health care, national security, and information technology. To address these challenges, we employ intelligent and committed staff who take care of our customers' success as if it is their own.

Duties and Responsibilities

• Perform concurrent and retrospective reviews of inpatient and outpatient medical records to ensure complete, accurate, and compliant clinical documentation
• Serve as the CDI Registered Nurse Advisor (RNA), applying nursing and clinical judgment to validate diagnoses, procedures, severity of illness (SOI), and risk of mortality (ROM)
• Issue written, verbal, or electronic provider queries to clarify documentation gaps
• Collaborate with physicians, licensed independent providers, coding staff, HIM, and revenue cycle teams
• Educate providers and clinical staff on documentation standards, CDI best practices, and regulatory requirements
• Assist in development and maintenance of the facility CDI program, including:
• CDI charter
• Standard Operating Procedures (SOPs)
• Workflow processes
• Turnaround time standards
• Participate in quality assurance, mortality reviews, utilization management, and CMS core measures
• Support reconciliation of CDI findings with final coded records and MS?DRG assignments
• Prepare and present weekly, monthly, and quarterly CDI metrics and reports to leadership committees
• Maintain compliance with VHA Directives, HIM Program Guides, Joint Commission, CMS, and ACDIS standards

Qualifications and Requirements

• Registered Nurse (RN) with a current, full, and unrestricted U.S. license
• Bachelor's degree required (Master's preferred)
• Minimum 2 years of CDI experience in an acute care hospital setting
• CDI certification from one or more of the following:
• AHIMA
• AAPC
• ACDIS
• Strong working knowledge of:
• DRGs and MS?DRGs
• ICD?10?CM/PCS
• CMS and Joint Commission documentation standards
• Ability to work onsite, MondayFriday during VA business hours
• No sponsorship available

All candidates must be able to:

• Sit, stand, walk, lift, squat, bend, twist, and reach above shoulders during the work shift
• Lift up to 50 lbs from floor to waist
• Lift up to 20 lbs
• Carry up to 40 lbs a reasonable distance
• Push/pull with 30 lbs of force

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

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