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

Role Description

This position is located in the Health Information Management Section (HIMS) of Health Administration Service at the Central Virginia VA Health Care System (CVHCS). Medical Records Administration Specialists (MRAs) in Veterans Health Administration (VHA) perform work concerned with the management of a health record program or the provision of services related to medical record administration/health information services.

• Classifying medical data from patient health records in the hospital.
• Analyzing and abstracting patients' health record documentation.
• Assigning alpha-numeric codes for each diagnosis and procedure.
• Serving as the liaison between Health Information Management and clinical staff.
• Facilitating improved overall quality, education, completeness, and accuracy of health record documentation.
• Reviewing documentation and facilitating modifications to ensure accurate severity of illness, risk of mortality, complexity of care, and utilization of resources.
• Identifying opportunities for documentation improvement.
• Querying clinical staff to clarify ambiguous, conflicting, or incomplete documentation.
• Reviewing the overall quality and completeness of clinical documentation.
• Providing education to clinical staff on inpatient episodes of care.
• Developing criteria, collecting data, analyzing and graphing results, creating reports, and communicating with appropriate groups and leadership.
• Obtaining corrective action plans from responsible clinical service chiefs.
• Monitoring regulatory and policy requirements affecting coded information.
• Using a variety of computer applications in day-to-day activities.
• Developing and implementing active training/education programs for clinical staff.
• Providing training in small and large groups on documentation standards and improvement techniques.

Qualifications

• Applicants pending the completion of educational or certification/licensure requirements may be referred and tentatively selected but may not be hired until all requirements are met.
• United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.
• English Language Proficiency.
• One year of creditable experience indicating knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records.
• Associate's degree from an accredited college or university 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.
• Equivalent combinations of creditable experience and education are qualifying for meeting the basic requirements.

Requirements

• Experience equivalent to the journey grade level of a MRT (Coder-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.
• Ability to collect and analyze data and present results in various formats.
• Knowledge of regulations that define healthcare documentation requirements.
• Extensive knowledge of coding rules and regulations.
• Knowledge of severity of illness, risk of mortality, and complexity of care.
• Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development.

Benefits

• Work Schedule: Monday-Friday; 8:00am-4:30pm.
• Telework: Not Available.
• Virtual: Remote 100%.
• Relocation/Recruitment Incentives: Not Authorized.
• Permanent Change of Station (PCS): Not Authorized.

Physical Requirements

The work is generally sedentary but requires use of fingers for typing, etc. May require light lifting and carrying (under 15 pounds). The tasks may require long periods at a desk working on personal computer or other piece of equipment.