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    The VA Northeast Ohio Healthcare System is recruiting for a Medical Records Technician (Coder) Clinical Documentation Improvement Specialist (CDIS-Outpatient). The Medical Records Technician (Coder) CDIS-Outpatient will function in Health Information Management section in Patient Care Administrative Service.

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    • 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.
    • Performing audits and analysis of medical documentation while providing ongoing education for clinical and administrative staff throughout the medical center and all surrounding community based outpatient clinics (CBOCs).
    • Serving as expert of current coding conventions and regulations related to professional and facility coding.
    • Performing audits of encounters to identify areas of non-compliance in coding and provide recommendations on appropriate coding.
    • Provides education to providers on the need for accurate and complete documentation in the health record, appropriate code selection of Evaluation and Management (E/M), Current Procedural Terminology (CPT) and ICD-10 diagnosis codes, and ensuring documentation supports the codes selected to the highest degree of specificity.
    • Prepare and conduct provider and coder education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding.
    • Maintaining current knowledge of various regulatory guidelines and requirements.
    • Utilizing coding audit results to identify processing inadequacies.
    • Planning, organizing, directing, and controlling areas with emphasis on data validation, analysis and generation of reports associated with the medical center's health information management program.
    • Retrieving, reviewing, and abstracting health record information.
    • Determining quality control measures needed.
    • Monitoring changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the medical center.
    • Ensuring proper code selection based on guidelines specific to certain diagnoses, procedures, and other criteria used to classify patients under the VERA program.
    • Maintaining statistical database(s) for results and validation of coding practices.
    • Using a variety of window based applications, such as Microsoft Outlook, Word, Excel, and Access.
    Work Schedule: Monday through Friday, 8:00 a.m. - 4:30 p.m.
    Telework: Available 2-3 days per week
    Virtual: Not Available
    Relocation/Recruitment Incentives: Not Authorized
    Financial Disclosure Report: Not Required

    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/559938900. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.