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 Kansas City VA Medical Center (KCVAMC).Learn more about this agency
Incumbent provides quantitative and qualitative review and analysis of medical records and encounter forms of both inpatient and outpatient encounters to ensure all diagnoses and conditions for which care is being rendered are documented by the provider in the proper sequence, and procedures have been documented and/or evaluation and management services.Major Duties include, but are not limited to:
- Analyzes physician queries as initiated by the coders, to identify those areas of documentation needing further clarification, to improve patient care and documenting trends by provider, clinic, and ancillary services for future in-service sessions, to ensure proper revision of problematic processes, forms, etc;
- Utilizes knowledge of the VHA Resident Supervision Documentation Guidelines, the Joint Commission, Centers for Medicare and Medicaid Services (CMS), and VA guidelines on medical record functions;
- Develops, completes, and coordinates internal monitoring and auditing activities to oversee compliance with documentation, coding, and billing issues and maintain reports of auditing activities, as well as follow-up reports when necessary;
- Assists with formal external reviews including but not limited to QuadraMed, Joint Commission, External Peer Review Program (EPRP), Office of Inspector General (OIG), System-wide Ongoing Assessment and Review Strategy (SOARS), Proclarity and VSSC;
- Assists in providing training process of encoder software, diagnosis/procedure code assignments, regulatory compliance, and data quality goals;
- Meets with Registered Nurse (Informatics) and other clinical providers, reviews documentation and coding, provides feedback concerning audits and monitors, and prepares formal reports for providers, clinical service chiefs and other facility leadership;
- Prepares and presents formal educational presentations to providers.
This is not a remote/virtual opportunity. This position may be authorized for Telework. Telework determination to be made by the supervisor of the position.
Functional Statement Title/#: Clinical Documentation Specialist GS-0675
This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/582181800. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.