This position is located in the Health Information Management (HIM) section at the Mann-Grandstaff VA Medical Center. The Medical Records Technician (CDIS) is responsible for abstracting medical record data and assigning codes using current clinical classification systems appropriate for the type of care provided.Learn more about this agency
CDISs are responsible for facilitating improved overall quality, education, and completeness and accuracy of medical record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, other patient caregivers, HIM coding staff and other associated staff to ensure clinical documentation and services rendered to patients is complete and accurate for appropriate workload capture and resource allocations. Develop and/or update medical center policy memoranda pertaining to documentation improvement. Serve as technical expert in health record content and documentation requirements. Responsible for performing reviews of the health record documentation; developing criteria, collecting data, graphing and analyzing results, creating reports and communicating in writing and/or in person to appropriate leadership and groups. Obtain appropriate corrective action plans from responsible clinical services directors, when necessary, and recommend improvements or changes in documentation as deemed necessary. Adhere to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policy and medical-legal requirements. Responsible for the development and implementation of active training/education programs (i.e. seminars, workshops, short courses, informational briefings, and conferences) for all providers to ensure the CDIS program objectives are met.
The incumbent works for the Mann-Granstaff Veterans Affairs Medical Center (VAMC). The position is organizationally aligned under the Health Information Management Section (HIMS) and is expected to work closely with all members of the health care team, Medical Center's administration, Site Managers' Offices, Health Care Administration and VAMC Executive Leadership. The incumbent will be required to periodically work and train clinical staff on documentation improvement opportunities at the VA Medical Center or any of our community-based outpatient clinics (CBOCs).
Work Schedule: Monday - Friday 8:00 a.m. - 4:30 p.m.
Financial Disclosure Report: Not required
Telework: May be authorized
Job family (Series)
This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/555611500. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.