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    The Medical Records Technician (Coder) Clinical Documentation Improvement Specialist is located in the Health Information Management (HIM) section in the Medical Administration Service at the Southeast Louisiana Veterans Health Care System. The Medical Records Technician (Coder) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.

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    Major duties include (but are not limited to):

    • 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.
    • Selecting and assigning codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare Common Procedure Coding System (HCPCS).
    • Developing and conducting seminars, workshops, short courses, informational briefings, and conferences concerned with health record documentation, educational and functional training requirements to ensure program objectives are met for clinical and Health Information Management (HIM) staff.
    • Facilitating improved overall quality, completeness and accuracy of health record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers and HIM coding staffto ensure clinical documentation and services rendered to patients is complete and accurate.
    • Participating in clinical rounds and may, where appropriate, offer information on documentation, coding rules and reimbursement issues. The documentation specialist is a member of the healthcare team, and as such, shall assist all clinical providers with ICD, CPT and DRG methodologies so that documentation will more accurately reflect the occurrence of the encounter.
    • Maintaining statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management.
    • Operating as a technical expert in health record documentation matters, providing advice and guidance in relation to issues such as documentation requirements, liability issues, advance directives, informed consent, patient privacy and confidentiality, state reporting, etc.

    Work Schedule: Monday-Friday from 7:30am to 4:00pm
    Financial Disclosure Report: Not required
    Functional Statement for GS-675-9 Clinical Document Specialist is available for review in Human Resources

    Travel Required

    Not required

    Supervisory status


    Promotion Potential


This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/533199900. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.