This position is located in the Health Information Management (HIM) section of the Health Administrative Service at the Lebanon VA Medical Center. The Medical Record Technician (Clinical Documentation Improvement Specialist (CDIS) - Outpatient) 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
- Facilitate improved quality, education, and completeness and accuracy of clinical documentation within the patients health record through interaction with clinical staff and HIMS coding staff to capture patient care services rendered and workload.
- Assists in developing and/or revising medical center policy memoranda pertaining to documentation improvement.
- Serves as Subject Matter Expert (SME) in coding based on health record content and documentation requirements.
- Responsible for performing reviews of health record documentation; developing criteria, collecting data, graphing and analyzing results, creating reports and communicating in writing and/or in person to appropriate leadership.
- Responsible for the development and implementation of on-going training/education programs (seminars, workshops, informational briefings, and conferences) to ensure proper health record documentation is compliant with all established requirements.
- Performs documentation and coding audits, providing results to providers and leadership via formal reports.
- Conducts initial and concurrent reviews for all admissions and identifies potential documentation improvements through periodic evaluation during the patient's stay.
- Monitors patient records for correct acuity of care are accurately reflected in the health record.
- 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, and as such, shall assist all clinical providers with ICD, CPT and DRG methodologies so that documentation will more accurately reflect the occurrence of the encounter.
Work Schedule: Monday - Friday, 7:30am - 4:00pm or 8:00am - 4:30pm
** This position is eligible for Telework**
** This position is not approved for Remote work **
Financial Disclosure Report: Not required
NOTE: Salary will be determined based on duty station.
Coatesville: $57,508 - $74,762
Lebanon: $66,930 - $87,011
A RECRUITMENT or RELOCATION INCENTIVE HAS BEEN AUTHORIZED FOR A HIGHLY QUALIFIED APPLICANT.
This job originated on www.usajobs.gov. For the full announcement and to apply, visit www.usajobs.gov/GetJob/ViewDetails/582774300. Only resumes submitted according to the instructions on the job announcement listed at www.usajobs.gov will be considered.