The Alexandria VA Medical Center is seeking a Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS)-Outpatient and Inpatient)). This position will be located in the Health Information Management (HIM) section at the Alexandria VA Health Care System.Learn more about this agency
1 position that can be located at either location.
Medical Records Technician (Clinical Documentation Improvement Specialist (CDIS-Outpatient and Inpatient)) is responsible for reviewing the overall quality and completeness of clinical documentation. Inpatient CDI focuses on the concurrent review of patient records with an emphasis on improving documentation while the patient is still in-house while 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.
The Incumbent reviews clinical documentation and provides education to clinical staff on both inpatient and outpatient episodes of care including admissions and discharges, observation, emergency department/urgent care, and clinic visits. They prepare and conduct provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding.
The incumbent compiles, reviews, abstracts, analyzes and interprets medical data incidental to a variety of patient care and treatment activities. Conducts daily reviews of all new admissions to designated clinical services to identify those with potential documentation improvements through periodic evaluation during the patient's stay. Reviews the health record and discusses the case with the clinical staff. Performs admission reviews for specific patient populations to facilitate appropriate clinical documentation and ensures the level of services and acuity of care are accurately reflected in the health record. Reviews the appropriateness of patient working Diagnosis Related Group (DRG) and length of stay information by reviewing all clinical documentation, lab results, diagnostic information and treatment to ensure documentation reflects severity of illness, acuity and resource consumption.
Additional duties as assigned.
Work Schedule: Monday thru Friday; 8:00 am until 4:30 pm
Recruitment/Relocation Incentives: May be authorized for highly qualified applicants.
Financial Disclosure Report: Not required
25% or less - You may be expected to travel for this position.
This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/582756400. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.