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Medical Records Technician (CDIS In/Outpatient)
Location
United States
Posted
6 days ago
Salary
$61.7K / year
Seniority
Mid Level
No structured requirement data.
Job Description
Medical Records Technician (CDIS In/Outpatient)
John J Pershing VA Medical Center
Role Description Responsible for reviewing the overall quality and completeness of clinical documentation. Inpatient CDI focuses on the concurrent review of patient records with an emphasis on improving documentation while the patient is still in-house while outpatient CDI focuses on improving clinical staff documentation of outpatient encounters. - Facilitating improved overall quality, education, and completeness and accuracy of medical record documentation. - Promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers, HIM coding staff, and other associated staff. - Developing and/or updating medical center policy memoranda pertaining to documentation improvement. - Serving as a technical expert in health record content and documentation requirements. - Performing reviews of health record documentation; developing criteria, collecting data, graphing and analyzing results, creating reports, and communicating with appropriate leadership and groups. - Obtaining appropriate corrective action plans from responsible clinical services directors when necessary. - Recommending improvements or changes in documentation as deemed necessary. - Adhering to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policy, and medical-legal requirements. - Developing and implementing active training/education programs for all providers to ensure the CDIS program objectives are met. - Applying comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures, and the principles and practices of health services. - Selecting and assigning codes from the current version of several coding systems including ICD, CPT, and HCPCS. - Adhering to accepted coding practices, guidelines, and conventions. - Monitoring ever-changing regulatory and policy requirements affecting coded information. - Assisting facility staff with documentation requirements to accurately reflect patient care provided. - Providing technical support in areas such as regulations and policy, coding requirements, resident supervision, and reimbursement. - Ensuring provider documentation is complete and supports the diagnoses and procedures coded. - Directly consulting with professional staff for clarification of conflicting or ambiguous clinical data. - Reporting incorrect documentation or codes in the electronic patient health record. - Using a variety of window-based applications in day-to-day activities, such as Outlook, Excel, Word, and Access. - Ensuring current versions of all software applications are loaded and functional after updates or changes. Requirements - Work Schedule: Monday-Friday 8:00am - 4:30pm - Paid Time Off: 37-50 days of annual paid time off per year (13-26 days of annual leave, 13 days of sick leave, 11 paid Federal holidays per year). - Selected applicants may qualify for credit toward annual leave accrual based on prior work experience or military service experience. - Parental Leave: After 12 months of employment, up to 12 weeks of paid parental leave in connection with the birth, adoption, or foster care placement of a child. - Child Care Subsidy: After 60 days of employment, full-time employees with a total family income below $144,000 may be eligible for a childcare subsidy up to 25% of total eligible childcare costs for eligible children up to the monthly maximum of $416.66. - 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). - Remote: Yes - This position is designated as remote. The option for remote work will be assessed continuously, and the selected individual may need to return to a VA office if required. The selectees must live within 50 miles of a VA Medical Center. Qualifications - United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. - Experience: One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records. - Education: An associate's degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study in health information technology/health information management, or a related degree with a minimum of 12 semester hours in health information technology/health information management. - Completion of an AHIMA approved coding program, or other intense coding training program of approximately one year or more that included courses in anatomy and physiology, medical terminology, basic ICD diagnostic/procedural, and basic CPT coding. - Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements. - Certification: Persons hired or reassigned to MRT (Coder) positions in the GS-0675 series in VHA must have either Apprentice/Associate Level Certification through AHIMA or AAPC, Mastery Level Certification through AHIMA or AAPC, or Clinical Documentation Improvement Certification through AHIMA or ACDIS. Grade Determinations - MRT (CDIS - Inpatient/Outpatient), GS-9: One year of creditable experience equivalent to the GS-8 of a MRT (Coder-inpatient/outpatient). - An associate's degree or higher, and three years of experience in clinical documentation improvement. - Mastery level certification through AHIMA or AAPC, and two years of experience in clinical documentation improvement. - Clinical experience such as RN, M.D., or DO, and one year of experience in clinical documentation improvement. Demonstrated KSAs - Knowledge of coding and documentation concepts, guidelines, and clinical terminology. - Knowledge of anatomy and physiology, pathophysiology, and pharmacology to interpret and analyze all information in a patient's health record. - Ability to collect and analyze data and present results in various formats. - Ability to establish and maintain strong verbal and written communication with providers. - Knowledge of regulations that define healthcare documentation requirements. - Extensive knowledge of coding rules and regulations, including current clinical classification systems. - Knowledge of severity of illness, risk of mortality, complexity of care for inpatients, and CPT Evaluation and Management (E/M) criteria. - Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development. Physical Requirements See VA Directive and Handbook 5019, Employee Occupational Health Service.
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