Clinical Documentation Improvement Specialist Jobs
Clinical Documentation Improvement Specialist jobs are open across health systems, hospitals, and physician groups, from entry-level auditors to senior specialists and CDI managers, with specializations in inpatient coding, outpatient documentation, and quality reporting. Find a role that fits below and apply directly.
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Showing 5 of 55+ Clinical Documentation Improvement Specialist jobs
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.
Learn more about this agency
This job is open to
The public
Clarification from the agency
NOTE: The 2-page Resume requirement does not apply to this position.
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
Conditions of employment
- 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
Basic Requirements:
- English Language Proficiency. In accordance with 38 U.S.C. 7403(f), no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English.
- Graduate of a school of professional nursing approved by the appropriate accrediting agency and accredited by one of the following accrediting bodies at the time the program was completed by the applicant: The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE); OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program. Upon achievement of a State license, the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program. (Reference VA Handbook 5005, Appendix G6); OR In cases of graduates of foreign schools of professional nursing, possession of a current, full, active, and unrestricted registration will meet the requirement for graduation from an approved school of professional nursing to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program. Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD).
- Current, full, active, and unrestricted registration as a graduate professional nurse in a State, Territory or Commonwealth (i.e., Puerto Rico) of the United States, or the District of Columbia. Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements, but do not possess the required licensure, may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.)
Grade Determinations: The following Scope, Education and Dimension criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade. The Dimension requirements (Practice, Veteran/Patient Driven Care, Leadership, Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment: https://apply.usastaffing.gov/ViewQuestionnaire/13102744.
Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.
Preferred Experience:
- Coding Credentials, Preferred
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.
Candidates should be committed to improving the efficiency of the Federal government, passionate about the ideals of our American republic, and committed to upholding the rule of law and the United States Constitution.
Benefits
A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new windowLearn more about federal benefits.
Review our benefits
Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.
How you will be evaluated
You will be evaluated for this job based on how well you meet the qualifications above.
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.
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.
If you are relying on your education to meet qualification requirements:
Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications. Therefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education.
Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.
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.
Agency contact information
510 Butler Avenue
Martinsburg, WV 25405
US
Next steps
Once your online application is submitted you will receive a confirmation notification by email. After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met. After the review is complete, a referral certificate(s) is issued, and applicants will be notified of their status by email. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.
You may check the status of your application at any time by logging into your USA Jobs account and clicking on Applications. Information regarding your application status can be found in the USAJobs Help Center.
NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). It is a requirement that all HCP to receive annual seasonal influenza vaccination or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccination has been granted. HCP in violation of this directive may face disciplinary action up to and including removal from federal service. HCP are individuals who, during the influenza season, work in VHA locations or who come into contact with VA patients or other HCP as part of their duties. VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities. HCP include all VA licensed and unlicensed, clinical and administrative, remote and onsite, paid and without compensation, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work at these facilities. HPTs may be paid or unpaid and include residents, interns, fellows and students. HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with patients outside VA medical facilities.
Overview
- 0610 Nurse
- Credentialing
- Suitability/Fitness
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.
Learn more about this agency
This job is open to
The public
Clarification from the agency
NOTE: The 2-page Resume requirement does not apply to this position.
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
Conditions of employment
- 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
Basic Requirements:
- English Language Proficiency. In accordance with 38 U.S.C. 7403(f), no person shall serve in direct patient care positions unless they are proficient in basic written and spoken English.
- Graduate of a school of professional nursing approved by the appropriate accrediting agency and accredited by one of the following accrediting bodies at the time the program was completed by the applicant: The Accreditation Commission for Education in Nursing (ACEN) or The Commission on Collegiate Nursing Education (CCNE); OR Individuals attending a master's level bridge program in nursing who have completed coursework equivalent to a bachelor's level degree in Nursing may have opportunity to become registered as a nurse with a state licensing board prior to completion of the bridge program. Upon achievement of a State license, the individual may be appointed on temporary basis and later converted to a permanent appointment upon successful completion and graduation from the bridge program. (Reference VA Handbook 5005, Appendix G6); OR In cases of graduates of foreign schools of professional nursing, possession of a current, full, active, and unrestricted registration will meet the requirement for graduation from an approved school of professional nursing to warrant an appointment as a Nurse who has completed an associated degree/entry level Nursing education program. Credit for foreign nursing education higher that associate degree/entry level requires a formal degree equivalency validation from a recognized equivalency evaluation accepted by VA such as International Consultants of Delaware (ICD).
- Current, full, active, and unrestricted registration as a graduate professional nurse in a State, Territory or Commonwealth (i.e., Puerto Rico) of the United States, or the District of Columbia. Graduate Nurse Technician (GNT) Exception: Candidates who otherwise meet the basic education requirements, but do not possess the required licensure, may be appointed at the entry step of the grade and level applicable to the completed nursing education as a GNT on a 120-day temporary appointment while actively pursuing licensure (may be extended up to two years on a case-by-case-basis.)
Grade Determinations: The following Scope, Education and Dimension criteria must be met in determining the grade assignment of candidates, and if appropriate, the level within a grade. The Dimension requirements (Practice, Veteran/Patient Driven Care, Leadership, Professional Development and Evidence-Based Practice/Research) are detailed for each grade and level within the online assessment: https://apply.usastaffing.gov/ViewQuestionnaire/13102744.
Reference: For more information on this qualification standard, please visit https://www.va.gov/ohrm/QualificationStandards/.
Preferred Experience:
- Coding Credentials, Preferred
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.
Candidates should be committed to improving the efficiency of the Federal government, passionate about the ideals of our American republic, and committed to upholding the rule of law and the United States Constitution.
Benefits
A career with the U.S. government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Opens in a new windowLearn more about federal benefits.
Review our benefits
Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time or intermittent. Contact the hiring agency for more information on the specific benefits offered.
How you will be evaluated
You will be evaluated for this job based on how well you meet the qualifications above.
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.
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.
If you are relying on your education to meet qualification requirements:
Education must be accredited by an accrediting institution recognized by the U.S. Department of Education in order for it to be credited towards qualifications. Therefore, provide only the attendance and/or degrees from schools accredited by accrediting institutions recognized by the U.S. Department of Education.
Failure to provide all of the required information as stated in this vacancy announcement may result in an ineligible rating or may affect the overall rating.
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.
Agency contact information
510 Butler Avenue
Martinsburg, WV 25405
US
Next steps
Once your online application is submitted you will receive a confirmation notification by email. After we receive application packages (including all required documents) and the vacancy announcement closes, we will review applications to ensure qualification and eligibility requirements are met. After the review is complete, a referral certificate(s) is issued, and applicants will be notified of their status by email. Referred applicants will be notified as such and may be contacted directly by the hiring office for an interview. All referred applicants receive a final notification once a selection decision has been made.
You may check the status of your application at any time by logging into your USA Jobs account and clicking on Applications. Information regarding your application status can be found in the USAJobs Help Center.
NOTE: Participation in the seasonal influenza program is a condition of employment and a requirement for all Department of Veterans Affairs Health Care Personnel (HCP). It is a requirement that all HCP to receive annual seasonal influenza vaccination or obtain an exemption for medical or religious reasons. Wearing a face mask is required when an exemption to the influenza vaccination has been granted. HCP in violation of this directive may face disciplinary action up to and including removal from federal service. HCP are individuals who, during the influenza season, work in VHA locations or who come into contact with VA patients or other HCP as part of their duties. VHA locations include, but are not limited to, VA hospitals and associated clinics, community living centers (CLCs), community-based outpatient clinics (CBOCs), domiciliary units, Vet centers and VA-leased medical facilities. HCP include all VA licensed and unlicensed, clinical and administrative, remote and onsite, paid and without compensation, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, researchers, volunteers and health professions trainees (HPTs) who are expected to perform any or all of their work at these facilities. HPTs may be paid or unpaid and include residents, interns, fellows and students. HCP also includes VHA personnel providing home-based care to Veterans and drivers and other personnel whose duties put them in contact with patients outside VA medical facilities.
Overview
- 0610 Nurse
- Credentialing
- Suitability/Fitness
Clinical Documentation Improvement Specialist Jobs by Experience Level
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What Employers Look For
The qualifications that appear most often in clinical documentation improvement specialist jobs.
- CDIP or CCDS certification from AHIMA or ACDIS required or strongly preferred
- Minimum three to five years of clinical coding or nursing experience in an acute care setting
- Proficiency with encoder and grouper software such as 3M or Optum tools
- Strong working knowledge of ICD-10-CM and ICD-10-PCS coding guidelines
- Experience writing compliant, non-leading physician queries that meet AHIMA standards
- Familiarity with DRG methodology, CC/MCC capture, and case mix index improvement
Tips for Your Clinical Documentation Improvement Specialist Job Search
List your query expertise prominently
Recruiters scan for your experience with clinical queries, so name the query types you've written, whether physician education, DRG validation, or CC/MCC capture. Quantify your impact on case mix index or documentation accuracy where you can.
Highlight your credential on the resume
CDIP and CCDS certifications carry real weight in hiring decisions. Place your certification directly below your name, not buried in a skills section, so hiring managers see it before they read another line of your resume.
Target listings by EHR and encoder platform
Many postings require hands-on experience with specific platforms like 3M or Optum encoder tools. Search for openings that name the systems you know, and call out your platform experience explicitly in your cover letter and resume.
Apply early to roles that fit
Migrate Mate lists clinical documentation improvement specialist openings from across the United States in one place, so you can find roles that match and apply directly to each listing.
Prep for a live query or chart review
Many CDI interviews include a practical exercise where you review a sample note and draft a compliant query. Practice writing queries that are non-leading and meet AHIMA and ACDIS guidelines before your interview so you can work through a case confidently under time pressure.
Negotiate scope before you discuss compensation
CDI roles vary widely in whether you cover inpatient only, outpatient, or both, and whether you own physician education. Clarify your scope of responsibility in the first interview so that when compensation comes up, you're negotiating against a clearly defined role.
Clinical Documentation Improvement Specialist Jobs: Frequently Asked Questions
Which companies are hiring the most clinical documentation improvement specialists?
The companies hiring the most clinical documentation improvement specialists right now include Optum, US Department of Veterans Affairs, and UASI, with the largest share of openings in New York, California, and Pennsylvania, based on current listings on Migrate Mate as of November 2026. Large health systems and academic medical centers consistently post the highest volume of CDI openings.
How many clinical documentation improvement specialist jobs are remote?
About 52% of clinical documentation improvement specialist openings are fully remote or hybrid as of November 2026, reflecting a broad shift toward concurrent remote review. Outpatient CDI and retrospective audit roles tend to be the most remote-friendly, while inpatient concurrent review positions are more likely to require on-site or hybrid presence at the facility.
How do you become a clinical documentation improvement specialist?
Most CDI specialists start with a clinical background in nursing, coding, or health information management, then build familiarity with ICD-10 coding guidelines and DRG methodology. Earning the CDIP from AHIMA or the CCDS from ACDIS is the standard credentialing path. Many candidates move into CDI from inpatient coding or bedside nursing roles, using those years of chart experience as their foundation.
Can you get hired as a clinical documentation improvement specialist with little experience?
Entry-level CDI roles typically require a strong coding or clinical foundation, so pure beginners are rarely competitive, but candidates with two or more years of inpatient coding or acute care nursing often qualify for junior or training-track positions. Completing a CDI boot camp or preparing for the CCDS exam signals commitment and can help bridge the gap when direct CDI experience is limited.
What does the clinical documentation improvement specialist interview process look like?
Most CDI interviews include a phone screen with HR, a technical interview with a CDI director or coding manager, and a practical exercise such as reviewing a sample note and writing a compliant query. Some employers add a panel interview with physicians or compliance staff. Interviewers commonly test your knowledge of CC/MCC capture, DRG assignment logic, and your approach to educating resistant physicians on documentation gaps.
Where can I find and apply to clinical documentation improvement specialist jobs?
You can find and apply to clinical documentation improvement specialist jobs on Migrate Mate, which lists current openings from across the United States. Find roles that match your credentials and experience, then apply directly to each listing from the job page.
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