[Hiring] Medical Records Technician (Clinical Documentation Improvement Specialist) @VA Maryland Health Care System

Role Description

The Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS - Inpatient)) is located in the Health Information Management (HIM) section of the Health Administration Service at the VA Maryland Health Care System. Medical Records Technicians are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings.

• Responsible for reviewing the overall quality and completeness of clinical documentation.
• Applies comprehensive knowledge of:
  • Medical terminology
  • Anatomy & physiology
  • Disease processes
  • Treatment modalities
  • Diagnostic tests
  • Medications
  • Procedures
  • Principles and practices of health services
  • Organizational structure
• Collaborates with clinical staff through written, verbal, or electronic clarification requests or queries.
• Reviews clinical documentation and provides education to clinical staff on both inpatient and outpatient episodes of care including:
  • Admissions and discharges
  • Observation
  • Emergency department/urgent care
  • Clinic visits
• Prepares and conducts provider education on documentation processes in the health record.
• Provides education to providers on:
  • Accurate and complete documentation
  • Appropriate code selection of Evaluation and Management (E/M), CPT, and ICD-10 diagnosis codes
  • Ensuring documentation supports the codes selected to the highest degree of specificity
• Assists facility staff with documentation requirements to accurately reflect patient care provided.
• Directly consults with professional staff for clarification of conflicting or ambiguous clinical data.
• Reports incorrect documentation in the electronic patient health record.
• Adheres to accepted coding practices, guidelines, and conventions.
• Expertly searches the patient health record to find documentation justifying code assignment.
• Queries medical staff and other clinical caregivers as necessary to obtain accurate and complete documentation.
• Uses a variety of computer applications in day-to-day activities, such as Outlook, Excel, Word, and Access.
• Develops and conducts seminars, workshops, short courses, informational briefings, and conferences on health record documentation.
• Ensures active intra-departmental training program is in place for HIM staff.
• Determines and meets training needs of extra-departmental personnel.
• Facilitates improved overall quality, completeness, and accuracy of health record documentation.

Qualifications

• United States Citizenship.
• Experience: One year of creditable experience indicating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health records.
• Education: An associate's degree from an accredited college or university with a major in health information technology/management, or related degree.
• Completion of an AHIMA approved coding program or other intense coding training program.
• Certification: Must have either:
  • Apprentice/Associate Level Certification through AHIMA or AAPC.
  • Mastery Level Certification through AHIMA or AAPC.
  • Clinical Documentation Improvement Certification through AHIMA or ACDIS.
• English Language Proficiency.

Requirements

• Knowledge of coding and documentation concepts, guidelines, and clinical terminology.
• Knowledge of anatomy and physiology, pathophysiology, and pharmacology.
• Ability to collect and analyze data and present results.
• Ability to establish and maintain strong communication with providers.
• Knowledge of regulations defining healthcare documentation requirements.
• Extensive knowledge of coding rules and regulations.
• Knowledge of severity of illness, risk of mortality, and complexity of care for inpatients.
• Knowledge of training methods and teaching skills.

Benefits

• Competitive salary and regular salary increases.
• 37-50 days of annual paid time off per year.
• Up to 12 weeks of paid parental leave after 12 months of employment.
• Childcare subsidy for eligible employees.
• Traditional federal pension and federal 401K with contributions by VA.
• Federal health/vision/dental/term life/long-term care insurance.
• Telework options available.
• This is a virtual position.