Medical Records Technician (Clinical Documentation Improvement Specialist)

For all assignments above the journey level, the higher-level duties must consist of significant scope, complexity (difficulty), range of variety, and be performed by the incumbent at least 25% of the time. Outpatient CDISs must be able to perform all duties of a MRT (Coder-Outpatient). CDISs serve as the liaison between health information management and clinical staff.
They are responsible for facilitating improved overall quality, education, completeness, and accuracy of health record documentation through extensive interaction with clinical, coding, and other associated staff to ensure clinical documentation supports services rendered to patients, appropriate workload, and resource allocations.
They review documentation and facilitate modifications to the health record to ensure accurate complexity of care and utilization of resources
They identify opportunities for documentation improvement by ensuring that diagnoses and procedures are documented to the highest level of specificity, accurately address all acute and chronic conditions, and reflect the true health status of patients. They recommend changes and/or updates to medical center policy pertaining to clinical documentation improvement.

Work Schedule: Monday- Friday 7:30am - 4:00pm (negotiable based on geographic location)
Remote: 100%
Functional Statement #: 000000
Relocation/Recruitment Incentives: Not Authorized
Permanent Change of Station (PCS): Not Authorized