Job Listing
Medical Record Technician (CDIS Outpatient)
Veterans Health Administration · Posted 53 days ago
Hybrid Bay Pines, FL $62K – $80K Apply by Jul 31, 2026 Medical Records Technician ISFJISTJ HealthcareTrades
Apply for this job → About the Role
The Bay Pines VA Healthcare System is a general medical and surgical facility, classified as a Level 1A Complexity. It is a teaching hospital, providing a full range of patient care services, with state-of-the-art technology as well as education and limited research. Comprehensive healthcare is provided through primary care and long-term care in the area pf dentistry, extended care, medicine, neurology, oncology, pharmacy, physical medicine, psychiatry, rehabilitation and surgery.
What You'll Do
- →Total Rewards of a Allied Health Professional Duties and functions of the Medical Records Technician - Clinical Documentation Improvement Specialist (CDIS) - Outpatient include, but are not limited to the following: Responsible for reviewing the overall quality and completeness of clinical documentation.
- →Outpatient CDI focuses on improving clinical staff documentation of outpatient encounters through retrospective, ideally prior to coding and billing, review of outpatient encounters and extensive provider education.
- →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.
- →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.
- →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 Veterans Equitable Resource Allocation (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 (VERA) program that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.
- →Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the VAMC.
- →Timely compliance with coding changes is crucial to the accuracy of the facility database as well as all cost recovery programs.
- →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.
- →Ensures provider documentation is complete and supports the diagnoses and procedures coded.
- →Directly consults with the professional staff for clarification of conflicting or ambiguous clinical data.
- →Reports incorrect documentation or codes in the electronic patient health record.
- →Expertly 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.
Requirements
- ✓You must be a U.S.
- ✓Citizen to apply for this job.
- ✓All applicants tentatively selected for VA employment in a testing designated position are subject to urinalysis to screen for illegal drug use prior to appointment.
- ✓Applicants who refuse to be tested will be denied employment with VA.
- ✓Selective Service Registration is required for males born after 12/31/1959.
- ✓Must be proficient in written and spoken English.
- ✓Subject to background/security investigation.
- ✓Selected applicants will be required to complete an online onboarding process.
- ✓Acceptable form(s) of identification will be required to complete pre-employment requirements (https://www.uscis.gov/i-9-central/form-i-9-acceptable-documents).
- ✓Effective May 7, 2025, driver's licenses or state-issued identification cards that are not REAL ID compliant cannot be utilized as an acceptable form of identification for employment.
- ✓Must pass pre-employment physical examination.
- ✓Participation in the seasonal influenza vaccination program is a requirement for all Department of Veterans Affairs Health Care Personnel (HCP).
- ✓Complete all application requirements detailed in the "Required Documents" section of this announcement.
- ✓As a condition of employment for accepting this position, you will be required to serve a 1 or 2-year trial period during which we will evaluate your fitness and whether your continued employment advances the public interest.
Personality Fit
Job ID: 31023962-db80-4547-99e1-188919c47848
Posted via USAJobs