Supervisory Medical Records Technician (CDIS)

Department of Veterans Affairs

The Supervisory Medical Records Technician CDIS position is located in the Health Information Management (HIM) section at the Loma Linda VA Medical Center. They are skilled in classifying medical data from patient health records in the hospital, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. Work with clinical staff to ensure accurate documentation in the EHR. Will do concurrent and retrospective chart review, etc.

• Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding. Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC. Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture. Develops performance standards and conducts performance evaluations for subordinate staff. Schedules the sequence of work and operations on a weekly, monthly and quarterly basis to assure even workflow and distribution, expeditious handling of priorities and the meeting of deadlines. Prepares workload and production reports; reports on operations and problems encountered; and presents proposed requests for resource needs based on past experience, anticipated staffing, equipment, and space. Formulates and issues written instructions and procedures and special instructions for non-routine or complex assignments or to clarify published guides. Reviews coding and assist coders in improving coding accuracy; provides coding guidance to various levels of staff to promote consistency in practice and compliance with coding rules and regulations; initiates various reports and analyze data; and coordinates, assigns, and monitors the workflow. Keeps abreast of all regulations and guidelines governing the coding section, ensuring that staff supervised is educated as needed Coordinates with other Service representatives on matters concerning health record documentation and coding, as well as changes and challenges that may have an impact on other Units or Services. Monitors the status and progress of work and day-to-day adjustments in accordance with established priorities. Required to train others on the encoder product suite. Has constant interaction with health care providers evaluating and communicating with the expectation on improving health record documentation which will result in improved patient care and improved revenue generation. Work Schedule: Monday - Friday 0730 - 1600 PST Telework: Not Available Virtual: This is not a virtual position. Relocation/Recruitment Incentives: Not Authorized. Permanent Change of Station (PCS): Not Authorized

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