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    The Medical Records Technician (Clinical Documentation Improvement Specialist) (CDIS) is located within the Health Information Management Section (HIMS) of the Business Operations Service (BOS) at the James E. Van Zandt VA Medical Center. CDIS are responsible for facilitating improved overall quality, education, completeness/accuracy of health record documentation through interaction with clinical, coding, and other staff to ensure clinical documentation supports services for patients.

    Learn more about this agency


    Duties include, but are not limited to:

    • The incumbent 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.
    • Develops and conducts seminar, workshops, short courses, informational briefings, and conferences concerned with health documentation, educational, and functional training requirements to ensure program objectives are met for all levels of clinical and administrative staff.
    • Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education to all members of the patient care team on an ongoing basis.
    • Technical expert in health record documentation matters, provides advise and guidance in relation to issues such as documentation requirements, liability issues, advance directives, informed consent, patient privacy and confidentiality, state reporting, etc.
    • Participates 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.
    • Reviews Maintain statistical databases 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.

    Work Schedule: Monday through Friday from 8:00 a.m. to 4:30 p.m.
    Financial Disclosure Report: Not required
    Functional Statement Title: Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient and Inpatient))

    Travel Required

    Occasional travel - You may be expected to travel for this position.

    Supervisory status


    Promotion Potential


This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/568770400. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.