[Hiring] Medical Records Technician (Clinical Documentation Improvement Specialist) CDIS-Outpatient @El Paso VA Clinic

Role Description

The Medical Records Technicians (RTs)-(Clinical Documentation Integrity Specialists) 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 Clinical Documentation Integrity Specialists (CDIS) analyze and abstract patients' health records and assign alpha-numeric codes for each diagnosis and procedure.

• Serve as the liaison between health information management and clinical staff.
• Facilitate improved overall quality, education, completeness, and accuracy of health record documentation.
• Review documentation and facilitate modifications to ensure accurate complexity of care and utilization of resources.
• Identify opportunities for documentation improvement.
• Recommend changes and/or updates to medical center policy pertaining to clinical documentation improvement.
• Serve as a technical expert in health record content and documentation requirements.
• Query clinical staff to clarify ambiguous, conflicting, or incomplete documentation.
• Focus on improving clinical staff documentation of outpatient encounters.
• Apply comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, and diagnostic tests.
• Provide education to clinical staff on both inpatient and outpatient episodes of care.
• Prepare and conduct provider education on documentation processes in the health record.
• Adhere to accepted coding practices, guidelines, and conventions.

Qualifications

• Reviews VERA input on missed opportunities in provider documentation.
• Ensures documentation supports codes based on guidelines specific to certain diagnoses and procedures.
• United States Citizenship required.
• Experience: One year of creditable experience in medical terminology, anatomy, physiology, medical coding, and health records.
• Education: An associate's degree from an accredited college or university in health information technology/management, or related degree.
• Completion of an AHIMA approved coding program or equivalent training.
• Certification: Must have either Apprentice/Associate Level Certification, Mastery Level Certification, or Clinical Documentation Improvement Certification through AHIMA or AAPC.
• English Language Proficiency required.

Requirements

• Experience equivalent to the journey grade level of a MRT (Coder-Outpatient).
• 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, MD, or DO, and one year of experience in clinical documentation improvement.
• Knowledge of anatomy and physiology, pathophysiology, and pharmacology.
• Ability to establish and maintain strong verbal and written communication with providers.
• Experience working with CDI metrics, developing excel reports, and presenting data to various committees.

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.
• Child care subsidy for eligible employees after 60 days of employment.
• Traditional federal pension and federal 401K with up to 5% contributions by VA.
• Federal health/vision/dental/term life/long-term care insurance options.

Company Description

This is a virtual position. The remote status of this offer is contingent upon final approval from the VA COO.