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Medical Records Technician (Clinical Documentation Improvement Specialist- Outpatient/Inpatient)
Veterans Health Administration · Posted 3 days ago
About the Role
This position is located in the Health Information Management (HIM) Section, under the Business Office, at the VA Medical Center, Atlanta, Ga. Medical Records Technicians (Coders) are skilled in classifying medical data from patient health records. These coding practitioners analyze patients' health records and assign alpha-numeric codes for each diagnosis and procedure.
What You'll Do
- →Major Duties Include but are not limited to: Reviewing the overall quality and completeness of clinical documentation.
- →Applying 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.
- →Reviewing clinical documentation and providing education to clinical staff on inpatient and outpatient episodes of care.
- →Preparing and conducting provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding.
- →Providing 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.
- →Adhering to accepted coding practices, guidelines, and conventions to ensure ethical, accurate, and complete coding.
- →Ensuring provider documentation is complete and supports the diagnoses and procedures coded.
- →Reviews documentation and facilitate modifications to the health record to ensure accurate severity of illness, risk of mortality, complexity of care, and utilization of resources.
- →Responsible for reviewing the overall quality and completeness of clinical documentation.
- →Inpatient CDI focuses on the concurrent review of patient records with an emphasis on improving documentation while the patient is still in-house while 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.
- →Queries clinical staff to clarify ambiguous, conflicting, or incomplete documentation and reviews the appropriateness of and responses to queries through review of query reports.
- →Obtains appropriate corrective action plans from responsible clinical service directors and recommend improvements or changes in documentation practices, when applicable.
- →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 that categorizes all VA patients into specific classes representing their clinical conditions and resource needs.
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: 1aa1d708-79d4-4005-a33d-3eb26ed25a64
Posted via USAJobs