Medical Records Technician (Clinical Documentation Improvement Specialist-Inpatient)

Department of Veterans Affairs

This position is located in the Health Information Management Section (HIMS) at the Central Virginia VA Health Care System (CVHCS) in Richmond, Virginia. The Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Inpatient ) MRTs (Coder) is skilled in classifying medical data from patient health records.

• As a Medical Records Technician ( Clinical Documentation Improvement Specialist ( CDIS- Inpatient), you will be responsible for classifying medical data from patient health records in the hospital. You will be responsible for analyzing and abstracting patients' health record documentation and assigning alpha-numeric codes for each diagnosis and procedure. You must possess expertise in ICD, CPT, and HCPCS code assignments. CDISs serve as the liaison between Health Information Management and clinical staff. Facilitates improved overall quality, education, completeness and accuracy of health record documentation through extensive interaction with clinical, coding, and other associated staff to ensure clinical documentation supports services rendered to patients, appropriate workload is captured, and resources are properly allocated. Review documentation and facilitate modifications to the health record to ensure accurate severity of illness, risk of mortality, complexity of care, and utilization of resources. Identifies opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity, accurately address all acute and chronic conditions, and reflect the true health status of patients. Queries clinical staff to clarify ambiguous, conflicting, or incomplete documentation. Reviews appropriateness of and responses to queries through review of query reports. 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. Knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection. Reviews clinical documentation and provides education to clinical staff on inpatient episodes of care including admissions and discharges, surgical cases, observation and professional services provided in the emergency department. Develops criteria, collects data, analyzes and graphs results, creates reports, and communicates orally and/or in writing to appropriate groups and leadership. Obtains appropriate corrective action plans from responsible clinical service chiefs and recommend improvements or changes in documentation practices, when applicable. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the CVHCS. Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs. Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite. Develops and implements active training/education programs (i.e. seminars, workshops, short courses, informational briefings, and conferences) for all clinical staff to ensure the CDI program objectives are met. Provides training in small and large groups, educates clinical staff about current documentation standards and improvement techniques, including accurate and ethical documentation practices. Work Schedule: Monday-Friday; 8:00am-4:30pm Telework: Not Available Virtual: This is not a virtual position. Functional Statement #: 000000 Relocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not Authorized

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