Medical Records Technician(CDIS-Outpatient and Inpatient)
- Full Time, onsite
- Veterans Health Administration
- Anywhere in the U.S. (remote job), United States of America
Salary undisclosed
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- 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 both inpatient and outpatient episodes of care including admissions and discharges, observation, emergency department/urgent care, and clinic visits.
- Prepares and conducts 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, appropriate code selection of Evaluation and Management (E/M), Current Procedural Terminology (CPT) and ICD-10 diagnosis codes, and ensuring documentation supports the codes selected to the highest degree of specificity.
- Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or evaluation and management (E/M) code to ensure ethical, accurate, and complete coding.
- Reviews VERA input on missed opportunities in provider documentation identified by the VERA coordinator and coordinate provider documentation education with the VERA
coordinator. - 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.
- Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
- Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing.
- Searches the patient health record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record.
- Uses a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite.
- Develops and conducts seminars, workshops, short courses, informational briefings, and conferences.
- Ensures active intra-departmental training program is in place for the HIM staff.
- Determines and meets training needs of extra-departmental professional, paraprofessional and non-professional personnel by originating training material.
- Facilitates improved overall quality, completeness and accuracy of health record
documentation. - Ensures the accuracy and completeness of clinical information used for measuring and
reporting physician and medical center outcomes with continuing education to all
members of the patient care team on an ongoing basis. - Assists in the development of guidelines for data compatibility, consistency, and monitoring for compliance.
- Provides advice and guidance in relation to issues such as documentation requirements, liability issues, advance directives, informed consent, patient privacy and confidentiality, state reporting, etc.
- Analyzes situations or processes and recommends improvements or changes in
documentation as deemed necessary. - Compiles, reviews, abstracts, analyzes and interprets medical data incidental to a variety of patient care and treatment activities.
- Conducts daily reviews of all new admissions to designated clinical services to identify those with potential documentation improvements.
- Reviews the health record and discusses the case with the clinical staff.
- Performs admission reviews for specific patient populations to facilitate appropriate clinical documentation and ensures the level of services and acuity of care are accurately reflected in the health record.
- Reviews the appropriateness of patient working Diagnosis Related Group (DRG) and
length of stay information by reviewing all clinical documentation, lab results, diagnostic
information and treatment to ensure documentation reflects severity of illness, acuity
and resource consumption. - Participates in clinical rounds and may, where appropriate, offer information on
documentation, coding rules and reimbursement issues. - Maintains statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices.
Work Schedule: Monday - Friday 8:00am - 4:30pm
Telework: Not Available
Virtual: This is not a virtual position.
Functional Statement #: 600880
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized
Starting at $59,966 Per Year (GS 9)
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