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

Role Description

MRTs (Coder) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. These coding practitioners analyze and abstract patients' health records, and assign alpha-numeric codes for each diagnosis and procedure.

Major duties include, but are not limited to, the following:

• 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.
• Outpatient CDI focuses on improving clinical staff documentation of outpatient encounters through retrospective review and extensive provider education.
• Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures, and health services principles.
• Reviews clinical documentation and provides education to clinical staff on both inpatient and outpatient episodes of care.
• Prepares and conducts provider education on documentation processes in the health record.
• Provides education to providers on accurate and complete documentation in the health record.
• Adheres to accepted coding practices, guidelines, and conventions.
• Reviews VERA input on missed opportunities in provider documentation.
• Assists facility staff with documentation requirements to accurately reflect patient care.
• Searches the patient health record to find documentation justifying code assignment.
• Provides advice and guidance on documentation requirements and related issues.
• Compiles, reviews, abstracts, analyzes, and interprets medical data.
• Conducts daily reviews of all new admissions to identify potential documentation improvements.

Qualifications

• U.S. Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens.
• Experience: One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and health records.
• Education: An associate's degree from an accredited college or university in health information technology/management or related field.
• Completion of an AHIMA approved coding program or other intense coding training program.
• Certification: Must have either a mastery level certification or a clinical documentation improvement certification.
• English Language Proficiency: Must be proficient in spoken & written English.

Requirements

• One year of creditable experience equivalent to the journey grade level (GS-8) of a MRT (Coder-Outpatient and Inpatient).
• 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 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 verbal and written communication with providers.
• Knowledge of regulations defining healthcare documentation requirements.
• Extensive knowledge of coding rules and regulations, including ICDCM and PCS, CPT, and HCPCS.
• Knowledge of severity of illness, risk of mortality, and complexity of care for inpatients.
• Knowledge of training methods and teaching skills for staff development.

Benefits

• Competitive salary and regular salary increases.
• 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).
• After 12 months of employment, up to 12 weeks of paid parental leave.
• After 60 days of employment, childcare subsidy for eligible employees.
• Traditional federal pension (5 years vesting) and federal 401K with up to 5% contributions by VA.
• Federal health/vision/dental/term life/long-term care insurance options.
• This is a remote position; telework is not applicable.