[Hiring] Medical Records Technician-Clinical Documentation Improvement Specialist (CDIS) - Inpatient @VA Northeast Ohio Healthcare System

Role Description

The VA Northeast Ohio Healthcare System is recruiting for a Medical Records Technician-Clinical Documentation Improvement Specialist (CDIS) - Inpatient. This position will serve within the Health Information Management Section under Patient Care Administrative Service.

The Medical Records Technician-Clinical Documentation Improvement Specialist (CDIS)-Inpatient duties include, but are not limited to:

• 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 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.
• Prepare and conduct provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding.
• Provides education to providers on the need for accurate and complete documentation in the health record, ensuring documentation supports the codes selected to the highest degree of specificity.
• Adheres to accepted coding practices, guidelines and conventions to ensure ethical, accurate, and complete coding.
• Ensures documentation supports codes based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the Veterans Equitable Resource Allocation (VERA) program.
• Reviews VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinate provider documentation education with the VERA coordinator.
• Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
• Develops and conducts seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM) staff.

Qualifications

• Citizenship: Citizen of the United States.
• Experience: One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of health records.
• Education: An associate's degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study 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.
• Certification: Mastery Level Certification through AHIMA or AAPC, or Clinical Documentation Improvement Certification through AHIMA or ACDIS.
• English Language Proficiency: Proficient in spoken and written English.

Requirements

• Physical Requirements: The work is mostly sedentary, requiring sitting with sustained periods of concentration, and may involve some walking, standing, bending, and carrying of relatively light objects.
• Grade Determinations: GS-9 level experience or education as specified.

Benefits

• Work Schedule: Monday-Friday; 8:00am-4:30pm.
• Pay: Competitive salary and regular salary increases.
• Paid Time Off: 37-50 days of annual paid time off per year.
• Parental Leave: Up to 12 weeks of paid parental leave after 12 months of employment.
• Child Care Subsidy: Eligible for a childcare subsidy up to 25% of total eligible childcare costs.
• Retirement: Traditional federal pension and federal 401K with up to 5% contributions by VA.
• Insurance: Federal health/vision/dental/term life/long-term care insurance.
• Remote: This position is designated as remote.